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GYNECOLOGICAL OPERATIONS 



HARTMANN 



Gynecological Operations 



INCLUDING 



Non-operative Treatment and 
Minor Gynecology 



By 

HENRI hJARTMANN 

morEssoR or thi faculty of iiidicin«, p«bii; surcbon to thi i^tKHsc himmial, fakii; 

HBUBBR or THK SdCIITY OF OHSTKTHICB AND OVHECOUiai: UIHBBII Or THB SOCIBTV OF 

EUROKRV; UIHBBII OP THB INTERNATIONAL SOCIBTV UF SltHCBRT: rORMBB. PRESI- 
DENT OF THE FRENCH COKORBSS OF OVMBCOLOGT; HONORARY FELLOW. CLIN- 
ICAL SOCIETY OF LONDON; HONORARY FELLOW. ROYAL COLLEOE OP 
SL'RGBONS, IEBLAND: SC, D.. TRINITY COLLEGE, ETC. 



AUTHOHEIED TRANSLATION UNDER THE AUTHOK's Si:PEHVISIOR 

BY 

DOUGLAS W. SIBBALD, M. B., Ch.B. Edin. 

P0BHBRI,T physician to the BRITISH HOSPITAL. LEVALLOIB-PEKRET. PARIS. 



WITH 422 ILLUSTRATIONS 
A NUMBER OF WHICH ARE IN COLORS 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

1012 WALNUT STREET 
1913 



ComiOBT, 1913, BY p. Blakiston's Son & Co. 



Tlir.UAI'LE-PIlIll>«'TunX>PA 



.5 



AUTHOR'S PREFACE TO THE TRANSLATION 



In the work we are now publishing we have endeavored to 
give as complete an exposition as possible of the diverse methods 
of treatment employed in gynecology. Although operative 
technic occupies pride of place, nevertheless non-operative 
treatment is also fully considered as there is a general return 
to-day toward this branch of therapeutics. For this reason we 
have considered it necessary to devote a place to minor gyne- 
cology, mineral water cures, kinestherapy, and electrotherapy. 
We have given special attention to procedures of choice and to 
the large number of our figures and diagrams, in endeavoring 
to illustrate each stage of an operation, whilst we have entered 
freely into operative procedures and the details of ante- and post- 
operative treatment. 

We have briefly described the procedures of other gyne- 
cologists and the numerous references will enable the reader to 
secure the original texts. 

With regard to the results or indications of the operations, 
we have always endeavored to consider their bearing on future 
pregnancies or the effect of pregnancies on the operations. 
We are of opinion that the work will be of value to all those 
who have to treat gynecological cases. 

Henri Hartmann. 



54323 



"TRANSLATOR'S PREFACE' 



The fact that Professor Hartmann's "Gynecologic Op^ratoire" 
has met with so much success since its appearance, shows that 
in some special way it has met the wants of gynecologists and 
students in France. The characteristics which have thus com- 
mended the work are its eminent practicality and its conscien- 
tious exploitation of a domain of operative surgery hitherto 
imperfectly dealt with in this country. 

In the task of translating I have endeavored to convey the 
author's meaning accurately by a rigid adherence to the original 
text. 

In conclusion I beg to thank Professor Hartmann, to whom 
I submitted the translation during its growth, for his help and 
unfailing courtesy. 

Douglas W. Sibbald. 

British Hospital, Paris. 



vn 



TABLE OF CONTENTS. 



PART I. 

Means of DiAONoais and of treatment employed in otnbcoloot 
CHAPTER 1. — The cunical examination in OTHEcOLOaT. 

SauuARY: Intbrbogation— pHYBicAi, examination; fikst, of thb abdoubn; 

SECOND, OF THE TAOINA; THIRD, EXAMINATION AFTER ANESTHESIA IN THE lAFT 
lATERAL POSITION, IN THE BTANDINQ POSITION, IN TBE flENUPECTORAL 

PoamoN; htstbroscopy 1 

Interrogation 2 

HeoBtruation 2 

Vs^nal discharges 4 

Swellings 4 

P^ns 4 

Extrauterine symptoms 6 

Ovarian insufficiency 6 

Physical examination 6 

Examination of the abdomen ,..,.. 7 

Inspection 7 

Percussion 7 

Palpation 7 

Auscultation 9 

Method of genital examination , 9 

Inspection 9 

Vaginal examination 10 

Bimanual examination II 

Rectal examination Ifi 

Examination with the speculum 15 

Appendix 18 

Anesthesia 18 

Left lateral position 19 

Standing position 19 

Knee-ohest position 20 

Hysteroscopy 20 

CHAPTER II.— Minor oynecolooy. 

Sumuary: Vaginal injections— Vaginal medication — To tampon the taoina 
— Catheterization of the uterus — Dilatation of thb CTKitna; first, 
rafidlt; second, slowly — Intrauterine ubdicatiom (lavaokb, miBO- 
TI0N8, LOCAL APPUCATiONa and CAtrsTics) — Drainage of the uterus — 
ATMOXAUBis^ZESTOKAuais — Bisr's method — PEsaARiBs — Curettino the 

UTERUS 22 

Vaginal injections 22 

Instrumenta 22 

Technic of vaginal irrigation 24 

Indications and contraindications to vaginal irrigation 26 

ix 



X TABLE OP CONTENTS 

Faob 

Vaginal medication 27 

Tamponing the vagina 28 

Catheterization of the uterus 29 

Technic . 30 

IndicationB 30 

Dilatation of the uterus .,......., 31 

Itapii] dilatation , 31 

Tftchnic 33 

Slow or gradual dilatation 34 

Instmmi'ntH required 34 

Technic 3fi 

Indications 36 

Intrauterine medication 37 

Intrauterine lavage 37 

Intrauterine lavage in the puerperal state 37 

Technic 39 

Complications 42 

Indications and contraindications 43 

Intruuteriiio injections 43 

Application of medicated bougies and of caustics to the uterine cavity 45 

I'roites for applying caustics 47 

Drainage of the utcruH 47 

AIniokuiiNiN , . , . 48 

Tec-liriie . 50 

(.'<(niplicutif)nB 50 

IndicalionH , 51 

Hier'K iricthiid 52 

IVuHaries 53 

Coniplii-utinnH to the use of pessaries 58 

IncliculionH fur the use of pcssaricR ... 59 

Ciirellinj; Ihe uterus , 60 

lliBtory aO 

Teclinic . , .60 

Anesthesia in ... 61 

Operaii'in in ......,,.., .... 61 

Complieiktions . , . , 65 

Idiiieulioni for 68 



CHAl'TEK III. — Physicai. agents in o*nbcologv. 
Sl'mm^kv: Klkitkotiikrapt (isaTROMEN'Ts, piiraiDiiOOicAL SAgBS, indications)— 

KlNKTUTMEIlAl'V^nYnmiTHKBAPr — ^MtNERAL WATERS 73 

Klectrotlicrapy 73 

InstrumeutM 73 

I'hyHio logical bases 73 

Indications ... 8t 

Organic lesions 82 

Kinctothcrapy 88 

Massage ... .89 

Movemenia 90 

Sismotherapy , . , 93 

Hydrotherapy 93 

Ilydrumincral treatment 94 



TABLE OF CONTENTS xi 

PART II. 

TXCBNIC OF OPERATIONS ON THE VCLVA, TAOINA, UTERUS AND ADNEXA. 

CHAPTER I. — Shroebt of the vulva. 

Pads 
Summary: Anatomical elements — Treatment of traumatic lesions (wounds 
AND contusions)— Treatment of inflammatory lesions (superficial 
AND deep) — Kraurosis — Leucoplabia and pruritus vulv« — ^Operation 

ON the vulva DIUINISBINQ IT (iNFIBRILATION, EPIBIORRHAPaT, NTMPHOR- 

RHAPHT) VuLVO-VAGINAL CONSTRICTION RADICAL OPERATION EXCISION 

OF THE CLITORIS, OF INFLAMMATORY LESIONS AND OF TUMORS (BENIGN AND 

malionant) — Treatment OF VAGINISMUS 98 

Elements of anatomy , . ■ 98 

Treatment of wounds of the vulva 101 

Treatment of coDtusions of the vulvs 101 

Treatmeot of infismmatory lesions 102 

Treatment of deep inflammatoTy lesions 104 

Treatment of kraurosts and leucoplasia 106 

Treatment of vulvar pruritus 105 

Operations on the vulva 106 

Operations constricting or closing the vulva , . . . 107 

Operations enlarging the vulvar orifice 107 

Treatment of cicatricial constriction 108 

Operations for excision , 110 

Removal of the clitoris 110 

Excision of inflammatory lesions Ill 

Extirpation of vulvar neoplasms 112 

Treatment of benign tumors 112 

Treatment of msUgnant tumors , 114 

Treatment of vaginismus 116 

Brusque dilatation under anesthesia llfl 

Excision of the hymen and of the vaginal entrance 116 

Plastic operations 116 

Resection of the internal pudic nerve . 117 



CHAPTER II. — SuROERY of the vaoina. 

Summary: Treatment of traumatic lesions (wounds, hematomas, foreign 
bodies) — Treatment of inflammatory lesions— Treatment of tumors 
(benign and malignant) — Treatment of strictures and atresia of the 
vaoina; formation of neo-vaginas 110 

Treatment of traumatic lesions (wounds) 119 

Treatment of hematomas 120 

Treatment of foreign bodies 120 

Treatment of inflammatory lesions ... 121 

Treatment of vaginitis 121 

Treatment of tumors ... 123 

Treatment of stricture and atresia of t}ie vagina 126 

Strictures of the vagina 126 

Vaginal atresia ' , 127 

Formation of a n^vagina 129 



xU TABLE OP CONTENTS 

CHAPTER III. — Plabtic opekatioms on the pebinb'cu and taoina. 

PlOB 

Sumuart: General tbchnic or plastic operationb — Treatment or pkbinbal 
TEARS, CoLPOPBRiNEOBBHAPar — Amtbbios colporbbapbt— Narrowinq 

OF THK VAGINA BT INTBODDCINQ VBTALLJC SUTCRBa — PaBTITIONIKO OF 

THE VAOINA, COLFECTOIIT TREATMENT OF RXCTTO-TAQINAL FISTULA . . . 136 

General technic of plastic operations 136 

Treatment of perineal tears 138 

Preventative treatment 138 

Curative treatment 139 

Immediate perineorrhaphy 138 

Secondary perineoixhaphy 141 

Late perineorrhaphy ... , 141 

Colpoperineorrhaphy 142 

Colpo perineorrhaphy by resectioD 142 

Veil's procedure . , . , 148 

Old and complete tears of the perineum . 148 

Old tears complicated by prolapse 14B 

Hegar's procedure '. . 160 

Colpoperineorrhaphy by division and splitting . 151 

Incomplete perineal tears 161 

Complete tear of the perineum 166 

Old tears complicated by prolapse 168 

Anterior colporrhaphy 162 

Extensive anterior colporrhaphy for colpocystocele , 163 

Various procedures 166 

Constriction of the vagina by metallic sutures 168 

Colpcclomy ... . . ,' 169 

Treatment of recto-vaginal fistulas 171 

Operation by the recto-vaginal route 171 

Operation by the vaginal route 174 

Operation by perineal route 174 

Operation by the vagino-perineal route 176 

rHAlTKH I v.— Operations on the cervix utbbi. 
Summary: Tkmphhahy oh oBriNiTE occi-tisioN of the cbrvijc — Tempoaaby or 

DEFINITE TRACHEI.1>T0U*, CoUTT'b AND PoZZl'S OPERATION TraCHELOR- 

HHAPUT BV DEVUDATION OR KLAPH AMPUTATION OF THE CERVIX, INFRA- 

VAOINAL OB SUPRA VAGINAL VARIOUS OPERATIONS BoUILLT's AND POUBY'b 

OPERATION — (.)PBHATIONH FOH UTBKINB FLEXIONS OPERATION ON THE 

CERVIX AND l'RB(i.NA\l-V 177 

Occlusion of thp cprvix 177 

Trachelotomy 178 

Pomi'h operation . 181 

Trachelorrhaphy . .... .182 

Trachelorrliaphy «-ith KuKace denudation 183 

Trachelorrhaphy with Haps ..... 184 

Amputation of the ciTvi.x ... , , . . . 184 

Two-flap amputation . ... 185 

One-flap iiniputalion 18G 

Supravafcinnl ampututioti 1S9 

Amputation with the knifiv . 190 



TABLE OF CONTENTS xia 

Paoi 

Amputation with galvanocaut«ry 190 

Various operations 192 

Scarification of the cervix , , 192 

. Bouilly'B operatioD 192 

Pouey's operation 192 

Operations for uterine flexion 193 

Operations on the cervix and pregnancy 19S 

CHAPTER V. — LiQATCKE of the uterine ahtemeb by the vaginal boctb. 

StJUHART: Geke'ral anatout — Operative technic — Indications 198 

Operative technic 200 

Indications 201 

CHAPTER VI, — Removal of pibkomata ar the vaginal route, 
StJMMAJtr: Removal or fibrous polypi and fibrouata of the cervix — Trans- 

VAOINO-VTBRIND UTOMZCTOUT TkaNSVAOINAL MTOUBCTOMI 202 

Removal of fibrous polypi 202 

Removal of cervical fibromata 203 

Transvagino-uterine myomectomy 204 

Transvaginal myomectomy 212 

CHAPTER VII.— CoLPOTOMiES. 

Suiiuart: Posterior colpotouy — Anterior colpotouv 213 

Post«rior colpotomy 213 

Fixing of the uterus in the vagina with the fundus below or"Bascule''of the uterus 217 
Anterior colpotomy 219 

CHAPTER VIII. 

Suiimart: Technic — Opebativb DiFFictrLTiEs — COMPUCATioNa — Vahiods pro- 
cedures — Operative uodifications according to the lesion .... 235 

Operative technic 236 

Operative difficulties 251 

CompUcations 252 

Operative modifications according to the nature of the lesion 261 

Vaginal hysterectomy in fibromata 263 

CHAPTER IX. — HYSTBBECTOMr by the paravaginal route. 

ScMUARV; History — Operation ^Results 273 

Histoiy 273 

Operation 274 

Results and indications 281 

CHAPTER X. — Perineal and sacral routes. 

Summary: Transverse and sagittal p grin eotoht—0 per axiom by the sacral 

ROUTE — Parasacral incision^ — Resection op the rectum 282 

■ Perineotomy 282 



xiv TABLE OF CONTENTS 

Paob 

TrftnsvPree perineotomy 282 

Sagittal perineotomy 283 

Parasacral route 283 



PART III. 

Operations bt thb asdohinal route. 

CHAPTER 1. — Srorten'ino of the RorHD LiOAUENTa in the 

INGUINAL HEOION. 

SuuHARV: Anatouical survey — Operative tbchnic — Results — Indicattonb . 286. 

Anatomical recapituIatioB 286 

Operative technic 287 

Results and indications 291 

CHAPTER 11. — AsDOMiNAi. celiotomt. 

Suumart: General technic — Operative precautions — Median celiotomy — 

Tranbterse CBUOTOur — Postoperative precautions — Complications . 293 
General technic of abdominal celiotomy 293 

Preparalory measures ... 296 

Operation 299 

Median celiotomy 299 

Abdominal incision ' . . . 301 

Transverse celiotomy , 320 

Complications of celiotomy , . 323 . 

CHAPTER III. — Abdominal hysterectomy. 

Summary: Abdominal hysterectomy — Types of procedure, various pro- 
cBouRES — Indioationb and modifications of technic accohdino to the 
nature or THE lesion 239 

Types of procedure . 32S 

Various procedures . . 338 

Hysterectomy by primary excisiun of the uterus 341 

Hysterectomy by continuous transverse section 341 

Hyslerectomy by uterine hemisection 343 

Total hysterectomy by subperitoneal decortication with primary openinfc of the 

post^'rior fornix and with preliminary hemostasix .... 345 

Indications for abdominal hysterectomy, modifications of technic according to the 

nature of the lesion 347 



CHAPTER I v.— Opehaticinm iis the tlhes and ovaiiies. 

Summary: Removal of the adnexa — Conhehvative i)peuation.'< on the tubes 

and ovaiiies 378 

Removal of the atlncxa '^78 

Conservative operation on (he ovary 3S9 



TABLE OF CONTENTS 



XV 



rr--ABI>OHrMAL 0PZRAT10X8 rOH DI&PLACBMSMD AKD SKVUTtOMN OF T1IK 
UTEUVS. 

Padb 

SCMUAKV: AWTtlUOH AOnOMINAL. UmTEHOl'tST— iNOIIlKtT IITBTCnOMIXT— ISCnU- 
AKOOMIKALKiltinTKNIKO (llf THK HOr.SD LIOatlBNT'^ CvSEOBroTBItBrTDUT 

I<«l«.VABDUMIXAt. OHOHTENINO OF TUS UTEI10§A(1UI. UUAUKNTH. 393 

Antvfior Abduminnl hy»lcrapex}' 303 

Indirect hyut^rupexy .... .198 

Intnftbdomiiiiil aharlcning of the round ligamenta 400 

Cun«ohy*t«r«oUiBiy . 40i 

lulnwlnhimiiial sliorlviiiag of the utvrosMral ligameols 40V 

CHAPTER VI.— SoMK lunE abdominal oi^katiox*. 
Bl-muaht: OBu-reHATioN oi- tub pouch op Dodui^b — Liuatvhk or nw trrintiKie 

ARTKIIT^I.IOATCKK OP TUB HTPOtiAHTHIt' VKINn — ItKDVCTInK OP UTXHIXB 
INVEHSIOK C^eTOPKXT . 

OblilcfBtion of t)ip pouch of Uougk-i 
Li^attirtt of tho iiUrinc urUry l>y (Ji<- ahdominni route 
Ligature of Iho liypogaatric veiuH . ... 

Itpduction of utrrine iiivrrsion liy the nhdominnl route 



Abdominal i^yHtofrexy 



407 
40T 
409 
411 
413 
412 



I 



PART IV. 

The TMEiupEcnc imucations is oiszABm op ntE cbnital xrMTEw or wouax. 

CHAPTER I —Til K ATMS NT or iNFi^tUMAToBr lesions or the ittkhvh a.vd adxbxa. 

StmiiAiiT: MrTnrns^EvoLirriON op PATHoaKMC caxcxPTioN and trkatmkkt — 
pRopHTi.Acnr trratmbkt— CrnATnT: tbestwf.nt op acute and chronic 

UKTIUTIb — iKDICATtUHH POH THBATUKNT up ACUTE AND CHKOXIC IfiPLAU- 

MATIOK or THE ADNKXA , . . ■ ...... ^ 413 

TrMtmriit of niFlritiB . . 413 

TltMlBipnt of inilanmiution of the ndnrx* 42:! 

CHAPTER II. — Thbathiuct op keopi^uhs or thk tn-BRDa and adxkxa. 

SOMMAiir: Utehike riunoUATA — KiKhouata amd preomahct — MAUaNAXT tv- 
MORs or THE i;tcrvs — Takcrii or the ckbvix and rBKoxAXcr — 

TUMOKH VT THE OVAHY 439 

Tmlmviil of iiti-rinc Rhroniuta _ 439 

PlbroUlB and t>rCKiiaucy 434 

Mali|n>Btit tiimiini of tlio uUrus 43fi 

Ut«riiie cancer aiid pregnancy 440 

Tttnon of tlie ovary . . . 443 

Tunoni of the ovary and pre^ancy 443 

CHjVPTER III.— Diiipi.»rEHBXTi> or the oTxurs. 
Bpumaiiv: Thkatmext or osnital prolapse— Means op fixation op the utkhi^b 

AKATOUU-rATHOliDOtCAL LEHIO.Sa (IP niOLAI'nE — I'MOI-HTLtC-nC tweatnbnt 

— Mboicai. tbeatmkst— Opkiiativk -ntKATMEvr — Treatukkt or vaoinal 
Ektkbocblk— Trkatme.vt OF it-iiiiiiME DKTiATioMt—ltniiti.vx i.tvxwuoifa . 444 
TraEtintail of ocnjlal prolnpHi* 444 



xvi TABLE OF CONTENTS 

Pxam 

Prophylactic and medical treatment 448 

Operative treatment 449 

Treatment of vaginal enterocele 457 

Treatment of uterine deviations 457 

Puerperal inversion . 457 

Polypoid inversioii 458 

CHAPTER IV. — Extrauterine prbqtjanct. 
Summaht: General indications for trbatment of extrautebine preonakct — 

TrEATUBNT of PRGQNANCY DUSINO FIR4T FIVE UONTHS IN THE ABSENCE OF 

COUFUCATIONS TREATMENT OF FERITONEAIi HEHORRHAOE OF &NCTSTED 

HEUATORRHEA EITHER INTRA- OB 8IJBPBRITONKXI. TREATMENT OF ItlEG- 

NANCT AFTER FIFTH MONTH OLD FETAL CTSTB 460 

Pregnancies observed in the course of first five months 461 

Pregnancy after the fifth month 462 

CHAPTER V. — Menstrual thocblbs and sterility. 
Summary: Menstrual troo bleb— Primary ob secondary amenorrhea — Men- 

ORRHAQIA^METROBRHAaiA DtSHBNORRHEA TROUBLES OF THE MENO- 
PAUSE — ^TrEATMBNT of STERILITY 465 

Troubles of menBtruation 465 

Amenorrhea 465 

Menorrhagia and Metrorrhagia 466 

Dysmenorrhea 467 

Troubles of the menopause 468 

Sterility 469 

PART V. 

CHAPTER I. — Operatiosb on the urinary appakatub. 
Summary: Intbrrociation — Examination of urine — ^Examination of the 
URETHRA — Examination OF THE BLADDER — Examination of the uretebs— 
Examination of the kidneys— Inthavebical separation of the urine — 

Catheterization of the ureters 471 

Interrogation 471 

Examination of the urine 472 

Examination of the urethra 472 

Examination of the bladder 476 

Examination of the ureters 478 

Examination of the kidneys ..... 479 

Catheterization of the ureters 479 

CILVPTER II. — Suroeky ok the urethra. 

Summary : Operations on the urethra — Theatuent of diseases of the 

URETHRA , . 481 

Operations on the urethra 481 

Catheterization, etc .... 4,S1 

Treatment of diseases of the urethra 487 



TABLE OF CONTENTS xrii 

CHAPTER III. — SuaoKBT or the bladdkr. 

Faob 
Suumahy: Opekationb on the bladder — Treatment op diseabes of the 

BLADDER 491 

Operations on the bladder . 491 

Treatment of diseases of the bladder , . . 495 

CHAPTER IV. — Treatment of uhinart fistulab. 

Sumuary: Vesicovaoinal fistulas — ^Prophylactic treatment — Preparatory 
treatment-— Operative TREATMENT — General technic — Simple Denuda- 
tion- — Treatment of fistulas situated opposite the cervix uteri — 
Operation in several stages — Special procedures applicable to 

LARCJE LOSSES OF tissue UTEROVESICALFISTUIAS UTEROVAGINAL FISTULAS 

AND DESTRUCTION OF THE URETHRA FlSTULA OP THE URETHRA, ETC. , , . 498 

Vesicovaginal fistulas 49S 

Prophylactic treatment 499 

Preoperative and operative treatment 600 

Treatment of fistulas situated in the neighborhood of the cervix uteri ...... 509 

Special procedures appUcable to large losses of substance 511 

Vesico-uterine fistulas 514 

Uterovaginal fistulas with destruction of the urethra . . 515 

Fistulas of the ureter . 518 

Nephrectomy 623 

Index 526 



PART I. 

MEANS OF DIAGNOSIS AND OF TREATMENT 
EMPLOYED IN GYNECOLOGY. 



I 

I 

I 
I 



CHAPTER L 
THE CLINICAL EXAMINATION IN GYNECOLOGY. 

Summary: Inlcrrognliun. — Phv^iiml t'^iiniiiinlioti first uf llu- uIidoiiK^n: 
second ijf tlic vagina; third, cxaminiitioii aitcr aiic§lhrsia in the left lalcrul 
jiOiiiilion, in the .ttanding posilion. in tlic f^vnu- pectoral ptwilioii; lij-dteroscopy. 

Bi-fore pi^K-eeding to the direct examination of the affected 
parts, wc should hIIow tho jwtieiit to state the reasons of her 
visit. While doing tliis we have an opportunity of observing 
her and of forming certain iinprt-sstons of her t/eneral stale, of 
her condition of embonpoint or emacintion, and of the color of 
her skin antt he-r inuroii.t viriuhrauf-i. We are thus ahle to rec- 
ognise in a greenish-yellow complexion, the subjects of chlorosis 
and nmenorrhea; in the extreme pallor of others, victims of 
menorrhagia : a tirc<l. |>ale. dull and ulinoat earthy aspect suggests 
U'ucorrhca, "uterine facies"; in the yellow straw-colored com- 
plexion we recognize the subjecLs of cancer; the emaciatinl 
ovarian facies denotes cysts, and contrasts with the volume of 
tlie abdomen: rumlly ii <lull leaden-colored face suggests a cun- 
(lilton of septicemia. 

Hiwevcr, we should not wait too long listening to tlie^ic 
preliminary examinations which are usually very long, rather 
confused, and which often enter fully into unnecessary details 
while neglecting points of capital importance: and thus give an 
idea of the general course of the <lispase and of the general 
condilion of the patient, but do not generally lead to a diagnosis. 

Therefore we should proceed to a rapid and methodical 
interrogation and not allow the patient to wander into uninler- 

ing <ligressions. 

I 




THE CLINICAL KX.AMINATION IN G\'XECOLOGV 



1. Interrogation. 

There is an advantage in conducting one's interrogation in a 
'^'•Mt order: 

(1) Menstruation. — The primary questions should concern 
pienittrualion. 

Some patients come to consult us for absence of menstruation 
or ameiunrrkm. I n a young girl who has gone beyond the average 
age uf menstruation, we must not necessarily conchidc thiit we 
have 1(1 deal willi a local allcction. In chlnrotic and lymphatic 
pntientji menstruation appears late; some months of jialience and 
a[iproprial<' tri-alment will decide the question at issue. If the 
amenorrhea persists we must think of a local affection such as 
abseniv <if ovaries, or uterus, or ;i genital im perforation. In the 
last named, at a given moment the whole of Ihe menstrual 
inolinien may come on (colic, pain in the kidneys, abdominal 
iH'aring down). .\t a more advanced stage, if the menstruation 
lias previously coniiucnced normally, amenorrhea may be symp- 
tomatic, of a grave general state or a cachexia (acute febrile 
affections, albuminnria, diabetes, tuberculosis, etc.) ; it may l}e 
due to a nervous cause and this is quite often observed immedi- 
nlelv afler marriage, or at a more advanced age. accompanied 
then by tympanites or abdominal poly.sarcia which may suggest 
to the doctor a pregnancy and may compromise his reputation. 
'I'his is a condition of spurious pregnancy de]>endent on a nervous 
origin. 

It Is important to fix the <jate of the last menstruation. The 
mind of the gxnei'ologist should l>e haunted by the idea of a 
|>oiU(ible pn'gnaiicy in the [>atient who comes to consult him. 
While on this subject rememl>er that one may Ik- deceived by 
the ignorance of the patient and her wilful deceit. In such a 
caae a.s the latter the patient wishes an examination to prcK'ure 
an abortion sctpienee. 

We slioidd not only determine the dale of the last menstrua- 
tion, h)il thr dtitvs oj the twa litat so as to be able lo determine Ihe 
non-inlerruption of the function. What the patient calls her last 
menstruation may in reality only be a symptomatic metrorrhagia 
of an abortion already [>assed or threatening. By finding out 
about the last two menstrualitms we avoid tliis pitfall. 



IKTERROGATION 

Hn\ing cleared up this point, we should study the nictislru- 
ation at all i'|HH'hs during the patient's life. Wlien did the 
first menstruation occur ? Did it come without diflicuUy 
and without pain? How has menstnutliuii itrogresscd since? 
Does the patient suffer during menstruation ? And if she 
suffers, do the painK come on liefore meiustruation occurs ? 
If the answer j-s yes, then we should suspect a probahle ovarian 
lesion. Again, if the patient suffers, does she do so when the 
meniitriial flow is established. In such a ease we think of 
some obstruction to the flow of blood from the uterus: stenosis 
of the cervix, either congenital or acc|uirt'd; uterine deviation, 
most often an anteflexion. If in the latter case, the patient 
descnl)es that after an aeeouchcmcnt she has remained six 
months, a year, or two years without suffering the existence 
of a mechanical obstacle to the escape of the blood, more particu- 
larly an anteflexion of the uterus is almost certain. After the 
enquiry into the painful .symptoms which may precede or 
accompany the menstrual ]>eriods, it is necessary to enquire 
as to their quantity and duration. As this quantity and duration 
varies in different women it is well to ask not oidy what actually 
comes awav but also what the habit was formerly and to com- 

* « 

pare the two. It Is thus easy to appreciate if there is really an 
exaggeration of the menstrual outflow, thai is. if there is 
vtcnorrhatj'm. Other iniportuut (piestions to be asked are: Does 
the patient lose blood in the intervals of the menstrual epochs, 
so-called " mftrorrka()ia"f Are the losses slight and inter- 
mittent? Is it a <|ucstion of a .simple ooiting of blood, or is 
the How considerable and continuous ? The replies to these are 
sometimes exaggerated, so It is Ix-st to determine approximately 
the amount of blood last by asking the numlier of dia]>ers soiled 
during the day. 

The study of the losses of blood is completed by enquiry into 
the character of the hemorrhagitr outflow. 

Does the woman lose fluid blood, or does it come away in 
clots? Is the loss accompanied by the expulsion of membranes, 
of "skin" as Uie patients say, or even of fetal n'UinanLs .^ All 
thejte questions are important ; they often allow of diagnosis being 
made even before local examination: for example, abortion 
(woman young, loss with clots after an interval), mural fibroma, 



4 THE CLINICAL EXAMINATION IN GYNECOLOGY 

nicnorrhagia in a woman somewhat oUler), or [lolypi (con- 
tinuous metro rrlingin), cancer (a wotnaii after the menopause 
Iiaving a hemorrhafjit- oiitHow, etc.), 

(S) Vaginal Discharges.— Does the palipnt complain of 
"whites"? And if these exist, is it a question of a recent iHs- 
charpe or does it tlale hack some months? lias it come on 
appai'eiitly without cause, or can the patient herself give it an 
cliology conncelirig it with some definite event in her genital 
life, altortion, accouchement, etc, ? What arc tlie characters of 
it.^ Is the discharge thick, ropy, viscous, odorless (cervical 
catarrh) 'f Is it purulent with an acid smell (simple vaginitis, 
the white discharge in anemic patients), or is it serous, some- 
times lightly tinted, of a putrid ndor (cancer) ? 

(3) Swellings. — Is the [Mitient a virgin in the true gynecological 
sense? Has .she lm<I children r How ni a ny ? Have they come 
at the term or l>efore it ? What sort of accouchements has she 
had.' Have tliey Uhmi diflic-iill .'' Has intervention been neces- 
sary? lias the ])erineuin heeii toni ? Has (he parturition l>een 
regular and complete ? I las the puerperium been compli- 
cal<*d by accidents (fever, vomiting, distcntitm of the abdomen. 
etc.)? Have there been abortions? What have been their 

tesiilLt ? 

(\) Palng. Although extremely variable in its intensity, 
jHijn is rarely absent' Is the pain in the inferior part of the 
aJidonu'ii and is it mediiin or lateral; or is it. on the contrar}'. 
a question of lumbar pains <ir of [>ains in the legs or a pain of 
coecygcxlyniii .' What are the characters nf these pains? Is 
there true pain or simply a sensjition of fatigue, of weight or 
a pain of utt!riiic colic, tearing-<lown |>ains. which the patient 
who has Wen a uintluT compares always with the pains of 
pnrlurition. 

The c<in<litiuns in which these pains occur have quite a 
siiecial imp<(rlance. We have already seen the significance of 
the pains winch iicenmpany or precede menstruation as reganis 
other pains; the Influence of repose or fatigue on them should 



' It mtiMt B<A be forfotton In Hi* aluily of paiB* in tlie rcKian of th« jwiiud arK»n» 
tliat liy«WTi« cnkv ba Urn onuw. Il ti uttvmnty Umhi l« March tor other riffm mruroaU 
inuniiiM, nuMwIyiilK, liit*na«l«l nnuralitiii, vto.). rrawmbOTiuf that h}'Bt«rift ntid eesii- 
ikl tnHiUi) nKjp oooxitt, Ihn Intirr li(«|iiD|t ii]> m rxoggtrntiog ihu pneml «rmplomii of 
IhefoniMr. 




INTER HOG ATI ON 



Iw noh^l. If the patient is relieved by rest in bed and only 
sulfcrs when she walks, one is dealing with a metritis. If she 
suffers even during rest in bed there is probably a lesion of the 
adnexii. This shows how important it is to determine the 
conditions giving rise to tin- syin|)t<>n), pain. 

Pruritus, vulvar or anal, constitutes a IhsI variety of the 
symptom, pain; it may be due to exterior cause (eczema, dia- 
betes, parasites), to the irritant action of a leucorrheal discharge, 
or again simply to a nervous cause. 

Having thus determined tJie ditferent functional symptoms of 
the patient as regards her genital organs, it is mt-essary to 
complete the examination, to examine her ivtiiaininj; systems. 

(5) Extrauterine Sjrmptoms.— t'n/mn/ tmubleit are frequent; 
they may even dnniinate the clinical picture so markedly as to 
make one Ijelieve it is an essential lesion of the bladder that pre- 
sents itself when really these bladder symplinns n>sull from a lesion 

the j^enitai organs. It suffices, it is true, to determine with 
^re the character of the symptoms observed to conned Ihcm 
with their true cause. If the pains appear more es|x'cially 
when the patient is upright and are more marked when she is 
fatigued, ami if the uriiu^ is clear, without deposit, it is not a 
question of cystitis but sinqjly of reflex bladder trouble, arising 
from some genital trouble that may !»■ determined by physical 
examination. It must be note<i. however, that Uie association 
of vesical and genital affections is frequent; it may Ije that the 
same agent has exercised its action on tlu- urinary as well as on 
the genital apparatus or possibly resulting from a"geuilal alTec- 
tion tlie bladder has bwn infected through its walls; or the 
bladder may simply be drawn on by adhesions following a 
pelvic {teritonilis, etc. The importance of rcrtat symptoms is 
not so great. Constipation, and even the cntero-colitis following 
it. is the habitual companion of gynecological lesions. It is 
often accompanied by gastric trouWes also; in fact, tliesc arc 
rarely al>sent. The relation between dyspeptic troubfex and 
lesions of the genital system is exiH-renccd daily. Vomiting and 
migraine are i)ften enough oI>5crved. In many women there is 
besides an association of lesions of sundry systems, genital 
alTeetion, flaccidity of the abdominal wall, enlcroptosis, etc. 

Recently a certain importance has l>een attached to the re- 




6 TIJR CLINICAL KXAMIXATION IN OYNECOLOGV 

search of a train of symptoms characterizing a faulty in- 
ternal st'crction of the ovary which Jayle gives as being char- 
acteristic of what he calls ovarian insufficirncy. Together with 
meiLslrual Irouhles, atnenorrhcA and dysmenorrhea, tliere exist 
in these cases, a group of vasomotor. m'r\'ous. and trophic 
symptoms, heat flushings, enfeeblement of racmury, modifica- 
tion of character, signs of neurasthenia and neuro-wuscular 
astlienia. adiposity or, more rarely, emaciation. 

"i. Physical Examination. 

It may seem, at first sight, to be useless or even somewhat 
ridiculous to impress the necessity of tliis physical examination; 
however, daily examples show that it is not at all a su]M'rfluou9 
recommendation and that this elementary precept is but too 
often forgotU-n. 

lis omission leads to very gross errors, of which it is easy to 
quote a few ex!im|)lcs. A young girl comes before us with an 
tlUlominal lunior; one passes in review all possible tumors, preg- 
luiney excepted ? How can one consider the latter jxissibilily id 
n voung girl, carefully brought by her mother, and never even 
hitving moiistriialcd.^ Considerations of even- kind lencl to show 
the iinp»Kssibililv of such a hypothesis. Yet on direct examina- 
tion, however impossible pregnancy may have appearetl. it is 
m»t«' the less pn-sent. Here is another case: A young girl who 
tMH Hill vet menstruated suffers from various strange symploras 
wUh MX'iniuglv no cause and for which she has followed all 
UuU* of (t^'ttlntenl. Direct examination at once .shows the exist- 
tHUV v<i •*» inuierfonite hymen, causing a henialoa)lpos, thus 
HtvUtK tho k«'V to nil the symptoms observed. There are examples 
»'\vii uuHv I-urious of the utility of this direct examination. 
M^iii.l. .(tK»t\« n »■««> of twins, each treated for many months 
^>l ivut ikUH'MorrlK'a: on making an examination he found 

Um» tho> %vfv in rrwlily two men with hypospadias, whose true 
wx ht"l not titl Iheu l»tvn rreogniwd through want of sufficient 

ll,\.L I.LI kl 1 1 lllll 

•iihl U' m» he^talion then in making a direct exami- 
U^Ul«U tW »UI ^'•Mt* whiTr the symptoms observed direct the 
%ti li* the tfvuttwl Irnct. 



pm'SICAt EXAMINATION 



Examination of the Abdomen. —To make an abdominal 
examination, the patient .sliould lie on a bed or on an ex- 
amining table; tlic legs strelclietl out, the arms alongside tlic 
body. The patient should be directed to breathe quietly and 
to let herself relax the niuseles of the abdominal wall, u eon- 
dition much more difficult to obtain than would be Ijelieved at 
first sight. 

Before beginning tliis examination, it should always be seen 
lo that the rectum and bladder are empty. It is a goo<i thing 
to provide one's self with a derinographic pencil so tliat one 
may at the time fix the resittlx of the examinatimi bij drawinij 
on the integument the outlines of the tumors which have been 
determineii by the various methodM of exploration. This outline 
has not only ihe a<lvantagc of giving lo tlu' observer a r^sum** of 
the results of his physical examination but it may also at the same 
lime facilitate the diagnosi.s by giving a graphic representatii>n 
of the most saliant and. significant points, that successive and 
as It were "parcelled out" examination would not have made 
so clear. 

'i'his precaution having been taken, the abdomen is exposed. 

Inspection. - Siin|jle inspecliun serves to ascertain any modi- 
fications of the integument there may be (venous or lymphatic 
varici's. pigmentation, streaks, etc), the existence of a general 
enlargement of the abdomen or any limited projection. In this 
lajut case it is to be determined what the precise position of the 
^welling is. wlielher it is median or laterul. whether it is smooth 
>r UfHlular, and if it moves or not with respiration. The form 
of the abdomen is sometimes of itself suflicieut to suggest cer- 
tain nmladies; an al>donien of a flattened ovoid shape with btdg- 
ing of the flanks suggests ascites; a bossy abdomen, jutting out 
niarkf<lly in front, a fibroma; an enormous belly falling iJown 
over the thighs, an ovarian cyst, etc. 

Percussion.— Hy percussion one can determine the form of 
the /.one of dullness, noting if this form is modified by changing 
the patient's position. It is tlius possible by this mode of expio- 
ration alone to make certain diagnoses and to differentiate, for 
example, between an ascites and an ovarian cyst. 

Palpation. — It is palpation which furnished, in most eases, 
most valuable and complete information. This [lalpation should 



8 THK CLINICAL EXAMINATION IX GVXECOLOOV 

!»: done softly, not with the ends u( tlit* (hitlers but wjlb the 
entire palmar surface of the liand' phit-ed flat on the al»clominal 
wall which is gently pressed in. onconmging the patient to breathe 
quietly an<l thus gain ground at each expiration. 

With ])atience one can almost uhvays ta-iuniph by the method 
against the muscular contraction which opposes the hand of the 
surgeon in pusillanimous ami nervou5 patientji.''' On the other 
hand, the thick layer of fat which lines certain abdominal walls 
renders [>ul[iatioit as difficult in it.s execution as uncertain in its 
results. 

In most cases, it is easy to determine by [lalpation the presence 
of a tumor, but sometimes one may have considerable doubt as to 
its exact position with reference to the different planes of the 
alHlominal wall. 

Ventral hernias are easily recognized by the bulging they 
make when the rectus musfles arc ctrntractrd. by their total 
or [)artial rc*iucahility, and by the depr^sability existing between 
the S4'parale recti. 

When a true tumor is present, it is again easy to determine if 
it i« parietal or intraalHlominal by an exceedingly simple little 
maneuver. While tlie patient is lying down, ask her to sit up 
while the surgeon continue palpating the tumor. If the contrac- 
tion of the alnlominal muscles i-anstnl by tJiis movement renders 
the tumor more prominent, at the same time not atfecting its mo- 
bility in front nf the contracted muscles, the tumor is preinuscular 
[Mirietal. If, while remaining j^roniinent and clearly preceptible. 
the tumor i.H immobilized by the muscular contraction, one is 
dealing with an intramuscular {Mirietal tumor. Finally, if the 
contracted muscle ma,sk the tumor .so that il is last on exploration, 
it is a cas<- of intraabdomitial tumor. Having localized the 
tumor, it^ form, mobility, and consistence must Ix* determined. 
I.S it soft or hani; fluctuating or not.^ Sometimes ]>alpation gives 
Meiisatioiis of u (|uite particular significance, such as the crepita- 
•lion cliarncterislic of peritoneal rubbing. If the tumor hanhnis 
uiiiler the hand, one may bo sure It is a case of gravid uterus. In 



' Tbo hand »ho»)<l Iw vnrtn. oihcrwiac » diB&gnwnbK' aenMlioa U ottuwd hy the 
*|if)IUttt(oi) ol » Milt hand un U10 «kiii of thp nlnloini-o. wluuh mky Mu*e (Ufciwlvf con- 
UsvtUmit of ihn ■txttmiinal wkII )iiti(]«ritie Uie t-\|i!ortilJ<iii. 

* Onp iiiu*t K<>i>T't aiciunrt twrloin LocnUKitt ooiiirsotiou* wliiefa pve ftXuvly th* iMiM- 
tluti of m liiriiM. 



PinSICAL EXAMIWTIOX 

other cases tbei'e is a sensation of a hard, mobile mass, striking 
against the walU at times, and seeming to float in a cavity; in 
brief, one has the sensation of ballottement. This is again in 
mast cases an obstetrical symptom dne to tlie movements of a 
fetus floating in the amniotic flui<l. Ortain tumors bathed in 
the h(|)iid of an ascites may give a similar sensation. 

Auscultation. — Auscidialion has not much importance in 
gynecologj'. It is of importance In diagnosing pregnancy, and it 
is quite unnecessary to niontioii here the pathognomonic signifi- 
cance of tlie sounds of the fetal hear! in this connection. The 
uterine souffle is of much h'ss interest, because if it is met with 
in pregnancy it is equally of common oceun-ence in cases of 
larfTf tumors, partictdarly fibroniiis. 

Method of Genital Examination.- The patient is placed lying 
on her back, the legs flexed on tlie thighs and these flexed on 
the JK-Ivis and placed in sliglit abduction. It is a good thing for 




Pig. I. — Patient in iioraal position. 



the patient to place her clased fisUs under her so as to raise the 
[jclvis slightly (Fig. I). 

Inspection. — One should start with the rxaminatimt of the 
vulva. ,\ftcr having noted llic aspect of the cutaneous side of 
the labia majora, se[)arate them and examine .sncce.ssively the 
other parts of the vulva (labia minora, clltons. vestibule, urethral 
orifice, hvraen or carnnculie mvrtiformes). The condition of the 
fourchctle, which may be torn, should be olwcrved, and before 
proceeding further with the exauiinatioii it is as well to ask the 
jtalient to bear <lo\vn which may cause some bulging imlicating 
iiti anterior or posterior colpocele which did not exist before the 
eHTort. 



10 



THE CLINICAL EXAMINATION IN GVNECOLOOy 



Vaginal Examination.— After examining iu this manner the 
vulva, the next thing to do is to make a vaginal examination. 
The hands should first be disinfected then methodically introduce 
the vaselined finger into the vagina by applying it first to the 
|>enneum and bring it gradually forward until it encounters the 
fourchetle; it then suffices to lightly press on this to enter, a 
coup sur, the vagina. 

Making its way gradually, the finger should explore the 
walls of the vagina, noting the stjiie of the niurous membrane. 
the existence of ulcerations or of fistulous orifices that may be 
there, the protrusion of tumors, and, lastly, any foreign bodies. 
Continuing to insinuate the finger gently the surgeon meet^ the 
cervix. However inexperienced he may be. he recognizes it 
easily by its rounded form, it^ firm consistence usually com- 
pared to the ti]> of the nose where the cartilages of the lobules 
meet. 

The condition of the vaginal forniccs which surround it 
should first claim the attention. Any increase in their depth 
indicates prola[>se. Normally the posterior fornix is deeper 
than the anterior. Its <!rplh. however, should not be excessive; 
that would be indicative of a malformation or a false marital 
pa-ssage. The pliancy of these fornice-s should be noted at the 
same time, also their obliteration by a juxta-uterine tumor. In 
case of a tumor, its characters should be determined which can 
be better done afterward by a bimanual examination. Having 
rapidly acquired an impression of the condition of the vaginal 
fornices, the sui'geou turns to lliee\aminittio)i of thet-crvix. What 
is its situation ? Is it near the vulva, indicating a jirolaitsed 
uterus ? Is it lying "en masse" forward against the sytn]ihysi5 or 
backward toward the concavity of the sacrum P In which direc- 
tion does the orilicc look? Does it look, as it normally does, 
down and back? Is the orifice rounded as in a nuUiimra or 
punctiform at the end of a long and conical neck ? Or is it. on 
llie contrary, the transversely split orifice of a woman who haa 
had children .' It is narrowed or dilated and, in this last case, does 
it give {Missagc |o a polypus, i>r to an cpithelioniatous intraccrv- 
ical vegetation, placental debris, or simply to the cen-ical mucous 
membrane in ectropion 'f Are there any tears present, and if 
these tears are commissural do thev continue towanl the 



PHYSICAL EXAMINATION 



11 



I 
I 

I 

I 

I 
I 



lateral fornix as cicatricial itidtirntioTis ? The exainiiiatiuii of 
tlie ccmx is finished by the appreciation of its volume and con- 
sistence, and any irri-friilarittes of its surface. This examina- 
tion, more rapidly made than described, gives fuller information 
than Niny be acquired by inKpeclion through a spcciiluni however 
prolonged. 

But, however precious the information acquired by this 
metliod of examination alone, it is not to be compared with 
a combination of this method and abdominid pal[Mit)on. 

Bimanual Ejavain&tioa.^l'ai/inalexiunimiliifn and abdominal 
palfHition combined constitute the most precious of the methods 
of g^'necological examination. This is really not a new method 
of examination; although every day in Germany one hears 
that the merit of having invented it some twenty years ago be- 
longs to Schultze. we know in France that it dates back much 
further and that introduced by Hinzos at the beginning of the 
nineteenth ccnturj', it was later brought into general use by Vel- 
peau and Courty. 

To put into practice the himnnnal ttiiOmd aj examination iJie 
palmar surface of the fingers and not radial border of the index- 
finger should iw used. One finger c»r Ijelter two, if the vagina 
is large, are introduced and kept in contact with the cervix. 
The external hand, phu-ed flat on the hypogastric region, exerts 
progj-cssivc pressure on the abdominal wall, while the patient 
breathes gently and does not contract her muscles. It is of ad- 
vantage to talk to her and gain her confidence. If the vagina is 
deep, the sacnd region should be slightly raised by getting the 
patient to put her fists underneath, press firmly against the 
perineum the interdigifal commissure, whilst the index-finger is 
in t)ie vagina, the median in the internatal fold, ami the thumb 
inclined toward the anal cleft. By this mctliod one can lengthen 
the finger from -1 to 6 em. 'l"he hypogastric hanil emieavors to 
hook the fundus of the uterus and to seize the body which is 
supjHirted by the fingers in the vagina pressing in the anterior 
fornix where the normally anteflexed uterus should He (Fig. lit). 
If the body of the uterus cannot he di.scovered by Uiis maneuver 
then it is nut in itf; normal pasitiun; it is then probably retro- 
verted and may be discovered by supporting it with the fingers in 
the |K)sterinr fornix. Once the uterus is seized it is easy by 



12 



THE CLINICAL EXAMISATroN IN GYNECOLOGY 



combined piilpation to appreciate its mobility in all directions, 
not forgctiiiig tJiat if the fixation of the iitoriLs indicates a |)athu- 
logica] condition an undue luobilily may inversely of itself be a 
source of trouble. 

After having tlius established the situation and mobility of' 
the iilerus, by combined palpation one can appreciate its con- 
sistence and volume that may Ih; ex[iressed by comparing it, 




Flo. 3 —^fcUon of [x-Irla Ahowine Ihr projfietlon of thp citvIk into lh<? vaRian. 
the nomuU tuiU'fli-xiuti ot Uii; uterus. kUo tbni Ihe depth of tlic jiofliiTior fumix in Hrnaitcr 
Uun Unit of thn wilvrior. 



4 



with llie volume of a gravid uterus at ii given period of gestation 
or by indicating the height uf the fundus above- Ihe superior ^ 
border of the pubic symphy.sis. bimanual examination allows V 
also the exploralinii of tlie broad ligaments and adtiexa. To 
effect this, tiie vagitial finger should be placed in one of the lateral I 
foniices and then pressing with the hypogastric hand the atxiomi- ' 



PHYSICAL EXAMINATION 



8 



I 
I 



nal wall above the Arcus Fallopii of the same side endeavor 
should lie made to seize the adiiexa between the vaginal fingers 
and the external hand. 

To reach most easily the right a<hiexa it is best to have the 
right hand the vaginal hand, and ince tvrsa to palpate the left 
adtiexa it is best to imikc the vaginal examination with the left 
hand, in this manner always turning the palmar faro of the hand 
toward the side to lie examined. 

Except in cases of s|>ecial difficulty, as for example a verv 
fat patient, one can thus palpate even healthy adnexa and 
appreciate their volume, consistence and mobility- 
All thest? manipulations of tlie bimanual esaniination become 
miieh easier when the [>atient is placed leith the pelvis elevated, 




¥n, Z. — Aa ndju>tabletjil)le.n'Jlh shoulder rrBt«,tiiKiil (or pelvioex&inin&tiona 



which |>osition we have adopted systematically for all our gyneco- 
logical examinations and which wc nblain by aid of an extremely 
simple table capable of being tilted at will (Figs. 3 and 4). 

The intestines fall toward the diaphragm; the pelvic cavity 
mes empty: the uterus and its adnexa, held by their attach- 
ts to the [K-lvic floor, remain only in place and separated 
from the intestines which nunnally surround them, ])ermit of 
being palpated with the greatest of ease. Thi.s position of 
dcvatioii of the |>elvis (45 degrees inclination) has also the 
ad%-anlage of emptying it of any tumors tliat may have fallen 



suup 
■^ 

■ 

I 



THE CLINICAL EXAMINATION IN GYNECOLOGY 




Pio. 4. — Bimanual examiaation with pelvis elevated. 







. ^ j^(^ |])0 pelvis ; the doited line marks the position the 
'"'*~' ~"r ^^^^inatW. the plain line the position occupied on 



PHYSICAL EXAMINATION' 



15 



into it (floating spleen. liydronf]>liro.sis in a movable kidney). 
Everj- tumor arising in the superior part of the abdomen rcltirns 
to its plaee of origin when tlic pelvis is raised (Fig- 5). It can 
be understood all the advantages aceruiiig from sucli a method 
of examination from a diitgnostic point of view. 

Rectal Examination. — Heetal examimitian is made in the 
ordinaiT manner. After having eovered round the nail of tlic 
index-finger witli soap, or better after having covered the finger 
with a rubber protector or one of gold-beater's skin, tlie anus 
and examining finger should lie well vaselincd. I'he finger is 
introduced at first in an upward and forward direction, then 
upward and backward so as to feci through the rectal wall, 
the cervix and body of the uterus. In palliological ca.se.s the 
bulging toward tJie rectum of rolleelions in the recto-uterine 
pouch, also the roots of the sciatic, may Ihu-s be palpatwl. It is 
a method of examination particularly useful in virgins; in case 
of necessity, it is in most cases possible even in them to do 
a vaginal examination without defloration ; it suffices to introduce 
the finger e.\tremely gi'iitly without .separating the leg.s. Excep- 
tionally, in order to appreciate alterations in the recto-vaginul 
septum a combination of rectal and vaginal examinations may 
be indicated. 

Examination with the Speculum. — The speculum does not 
five nearly such good results as the bimatmal examination. 
With a little experience the latter informs us of all that we 
might Icam by the use of the speculum and in addition gives u.s 
impressions of existing conditions which the speculum is unable 
to do. The part the s[ieculum plays in an examination now- 
a-days is very restricted and is not regarded as of the same 
great importance as was the ease during the last twenty years. 
Its use is contraindicated when any obstruction exists to its 
introduction, such as a hymen, an acute inflammation, any 
contraction; or in cases of vaginismus, or finally in the event 
of a recent wound of the vagina or vulva which the speculum 
might disunite. The forms of sjicculums are numerous;' they 
can be classified into three groups, the bivalve type, represented 



' Wr do not dotHtribc hcto nil the vuHuu* modoU of «jiL-riiti>. Thosv wbu wi> interested 
in the bialoiy cf Iht^ a|)Coii]uiu will fiui) an article liv Jnyle ^/Vifinr midiralK. February 10, 
IWM. p. S9I) (loUilinR ita hiKtory from th« time of Ahlnioan* U> r.ho pRMwnt day. 




16 



THE CLINICAI. EXAMINATION IS OYNECOlLiGY 



by f'u-Sfo's; the (-yliiulrical type generally etiiidoyed is tluit of 
Ferjiusson; the "'(JuckliiH" or sinftlc-valvf lyjie is best known 
under the name of Sims. It appears useless to describe liere 
these speeulums wliidi are in evorj'day use. (See Figs. 6, 7, 8 
nnd 9.) 

In a general way tlie valvular siH'culums have a fixed point at 
tht; level of the vulvar orifice where a screw or lever enables the 




Fia, ti. — (.'ubco'b IjivhIvi- spncutum. 



Fi«. 7. — Jaylc'n bivalve with a double 
movsmpnt,. 



blades to be opened and thus distend the vaginal cavity without 
atTi'cting the oriKce at the vulva. The cylindrical speeulums are 
made of vulcanized rubber, celluloid, glass, or of nielal. and have 
one expanded extremity, while t)ie other is shaped like the mouth- 
piece of a flnt<' to facililHlc its introduction and to accommodate 
itself l>etter to the cervix, seeing that the posterior fornix is 
deeper than the anterior. 





Pm. 8. — Fergutison'a cyliudrical apeuulum. i-'io, 9.— Simii' "duckbill" gpecutmn. 

In order to inlroduce a hiimtve specidum^ vaseline it first nnd 
having .separated the lal>ia with two fingers of the left hand, take 
tlie speciihini in !hc riglit and inlroduee it in such a fashion ttuit 
its "beak." so to speak, is parallel to the main axis of the vulva. 
One glides it past the vulvar orifice by strongly depressing the 
fourchette, thus avoiding contact with the region of the vestibule. 
Having |)a.s.sed the vulva a rotary niovenu>nt is imparted to the 
speculum turning through a quarter of a circle by whicli the 



PHYSICAL EXAMINATION 



17 



I 



blades come lo lie In the liori/ontiil phiiic niid are ndvanccd 
further into the vaginiil eavity. In the majoritv of cases, if the 
vulva is large enoujjh it is simpler to depress the fimrchettc 
strongly with two fingers of the left hand and introduce the 
8[icculuin directly into the vajiina. One should heware of 
pushing in the specuhim recklessly, as tlie inexperienced usually 
do, hill direct it in Oie direction already ascertained by the digital 
examination per vaginam, a proreeding tchich should always be 
earrie^l out as o preliminary measure. 




I 



Flo. 10-^ — InlroduRtion of thn bivalve six-ciihiin. iTliP oriociilum ifl introductd 
obliqnet)' In order to raoilitalv its entry iiiiu i\u< vulvar urillcf ami ihen cootiDUcd hori* 
■OOtJtlly when oucL' in the vagiiia.) 

The examination of the cervix is rendered easier by keeping 
in the center of the visual field *»r the speculum the .star-shaped 
fonnation produced by (he folds of the vagina] mucous membrane. 
Having found the cervix, the two lila<Ics are more widely sepa- 
rated, by the screw or lever apparatus, to the extent required, 
but should avoid a too great sejKirHtitin. as this may prcKliKT an 
artificial eversioii of the cervix, which may be mistaken for a 
pathological condition. 

To remove the speculum, liegin by allowing the two valves 
to fall together, without allowing them to meet; in order not to 





I 



■ i 

s ' 



pinch tip tliv niupoiis inombrano ami to Imve an opportunity 
of I'xuniiuing the vaginal walls as they slowly fold at the t-xlreiiiity 
of the .speculum. The instrument is withdrawn by a rotatory 
iDovcnifut, the reverse of that employed in its intrmhiction. 

In ortler to introduce the cylindrical speculum firmly depress 
the fmirchetiv and introduce the tip of the flute-like mouthpiece 
of the ^iwouhim below, thus avoiding catching the inferior [>art 
ol Ibp urethra above; the speculum is pushed on toward the 
cfTvix by pn>gressive rotatorj- movements. Having found the 
«T\'ix. which .should be enclosed in the sppfulum, maneuver 
the yjieculum so that the projecting or free portion of its cxtr^-mity 
waUowvd to occupy the posterior fornix. 

U Ibe unimlvf apecidun is employed, of which Sima* duckbill is 
% tjryti wf make a slight pressure on the posterior commissure 
«il^ ibdvnwx side of the speculum and then gently insinuate^ 
ikii^ Umf vulvar orifice; then as it is further introduced it comca^^ 
l» ti» «(e<^li>t the recto-vaginal septum. If it i.s gently pushed 
% 1|ttt» Atcthef. \\T will be able to feel a slight resistance and 
tklM«vknow thtit we have n.>achcd the extremity of the vagina. 
Jttt ^ImI thim r\-mains is to ]iress down the hand firmly, depress 
1^ teuivWttv> and lit the same time to lever the instrument io 
^« «^ a» to apply greatest pressure on the extremity in the 
't\» ntMtlU in the maximum dilatation of the posterior 
I 4iMt MMMfS US to see the ciTvix. As at each ins])iration 
"»twnl wall interferes with the view of the parts, 
?i A tingrr or u siiudler sprculuin of the same type. 
tycv-WI ii).strumeut for the purpose. 



3. Appendix. 



. |Ih> i-xniiiitiiition may Ik- (.■<mi plicated by the 
•nfim ^\<rfin\ teclmic. 
^__^ 4 ^Yrti«t<-iil i-<inlriicli<iti uf Ihe iiiu»C'U-<i of the 
( ^ ««>fv (lainf III iinlurr juilify us in the employ- 
if^<j«ttoui ruttuiiisliitn nir'ii.-iun-* it iniiv lie used. 
i^pwiw aBTvlheoiii fnr this piiqtoM-. l\e would 
, fMcr|iH. iJruH il <ltiun lowtinl Ihc orifice 
I k.oulant. and then study the mobility 
ma to lt»f utcrtiH. We, however. l>clicTe 



that by the bimaoual pxaminalion and the Trcndclcuburg jiosition, we can 
<]ii>)>cn.M^ with all IhrHV <-<>ni|ili<-atc(l miuicuvers and with nno-ilhcsia. which 
latter is not without a ccrlain denirtit of gravity, and iinfortuiiuU-ly Nii|i|ireKS4^x 
much u^til infoniiation which may be gathered from the inveiitigation of the 
conditions of existing pain. 

Left Lateral Position.— 'rh« cxnmmation in the left lateral position 
was formerly much employed by American gynecologists. The pulirnt 
Iks on her left Kide on a firm resintant .lurface, the head supported 
on a cushion. The left arm hangs over the edge of the table: the 
thighs and knw* of both exlri'inilies are fleiccd and the right i» more tle\ed 
and carried forward, as the pelvis is inclined toward the table, ils movable 
contents fall forward toward the anterior abdominal wall, thus permit- 
ting the vagina distending. Sims' duckbill speculum is employed. Raise 




FiQ. ll.^Left Utcrnl poiitinn. 

the labium major with the left hand and introduce the speculum with the 
concavity of the blade looking down. Once post the vaginal entrance, incline 
the instrument slightly back so that the coni-avity look-t forward, nnd as it 
Is gradually introduced, further support it continually against the posterior 
vaginal wall. When t!ie blade U in place, hand it to an os^i.ttitnl who with 
his right hand draws it backward and slightly across the upper buttock. 
while with hit left lutnd he niiHes the ii))pi-r labium major and the upper 
buttock. This position permits of a good examination of the vagina. At 
all limeH when there are inllaniinatory exudates in the pelvis the uterus 
remains fixed and the vagina docs not distend well. This mode of examina- 
tion i* not nuii'h eniployed in France. 

Standing Position. — The patient's Imck rvstx against a wall or a piece 
of furniture. The surgeon kneels on his left knee, sup|>orting his elbow on 
his semiflexed right knee, and in this position he niakrjt a digital vaginal 
rxami nation. 

'ITiis method is indicated in s|M-(rial cases where one wishes to delcr- 
thc degree of a prolapse and particularly to investigate the cfBeocy 




20 



THE (TUXICAL EXj\Mn»"ATro.\ IN (iV.VICCOl.OGY 



of a pessary lo remedy the prolapse; it is useful also to determine fetal 
"biilliilti'nii-nt." 

Knee-elbow Position. — In Ihis position, greatly used in America, the 
pntirnt kneels on the table, the trunk sharply inclined downward and for- 
ward: the head on the tahle is tiinifftl to one side or the other and the breasts 
mx cIospIv in conltict with the table as possible. In this position Ihi- pelvic 
contents Fall toward Ihe anterior iilxhiininal wall as in the left lateral position, 
but more nuirkedly; also the moment that one partly opens the vajjina by 
the introdnction of a simple valve speculum, which lifts np the fourchette. 
tlie air »>nler>i and dilates the vagina, enabling us to examine its walls quite 
easily. It is the best position fur the cxaniIn»lion of a virgin. 




l2.^^enu-pcctora1 position. 



One has only to introduce through the orifice of the hymen (while the 
patient is in the kn('<'-eI!Hiw pcisitioii) a tube provided with a inandrin of 8 
to 15 mm. (J' — s") diameter. The tube beinjj introduced, tin; mandrin 
ts drawn out and the vafjina distfiiding us a result of the entry of air. it 
may he easily examined in its entirely provided the light is sufficient. 

Hysteroscopy.— Ilysleroscopy or uterine endoscopy was recommenderl 
in France by Duplay and ('lado who used a tube and a photit|diore ur light- 
prodncing apparatus. David.' who has recently taken up Ihc study of this 
question, uses » tulw with an internal light likf Valentine's ur^^th^oscope, but 
closed at its extremity with glass to avoid contact of the lamp with the blood 
oozing from the nt<-ri[ic mucnus nicndirane. The uterus is (ir>>l dilated and 
then drawn down. The tube fitted with a mandrin is introduced into the 
uterus as far a» tiie fundus: the mandrin is then withdrawn and replaced by 

' I'roufJSrt-' (Z). Contribution i I'tlude dr VhyslfToteiipit. Th. -U I'aris. 1898-1899, No. 
69.— RnuUner. C*nt. HI. f. <t<jn.. Ixiv^ii. 180S, No. 22. ji. SSO.^Duvid, AnnaU* lU Omi. 
n d'ObtUi.. Piait, Sopl., 1908, p. &li. 



APPENDIX 



21 



Ihc interna) tube filtiMl with glas§ over its i>.\trt-niity, Once tin- liitn|) i» in 
placr. one cnn bcjfin by «'xnmiiiiiig Uie intornnl BMrfiicc f>f llio utorus, com- 
mencing at the fumlu.'i and then the rest of the cavitj", jiraduallv willidrawing 
and at the name time rirciimductiiig the instrument which enables the light 




Fio*. 13. 14, ADil 15— David's liyiit<Ta«iop«. 
Above the inotruinent cam|ilete. Uelow tlie nxtfnial tubb wiui Itn mutdi-ln and llien 

t}ie [nl«nial tuli«. 

lo the tube to make a complete tnur, so la »i)cak, of the whole tif the uterine 
caTily. 

Up to the present, thin method of examination is not conimon. Person- 
ally, w« iinve never Iind recourse to it. 



CHAPTER 11. 

MINOR GYKECOLOGY. 

Conteats. — Vaginal injeclions. — Vaginal medication. — To tsii)|M>n the 
vagina.— ^^Btiii-UTiztitiun of the iitcrii*, -nilntdtion of the utrrus: Gisl. 
rapidly; second, slowlj-. — InlrauliTim- inoilicaltMn (lavages, injwiioiw, 
local •()plicatiun« and caustics). — Drainage of the uterus. — Atinokausis. 
— Costokausia. — Bicr',s mettiod. — PcMarics. — Curetting of the uterus. 

1 . Vaginal Injections. 

The siinplicih" of the Ireatnietit of utero-vaginal affections by 
iiijcction.s [ms made tliis iiurttux] one 0.40(1 for all time. For a 
long time the incontestable influence they exert in certain cases 
hus been the .subject of nnieh study, and whelhcr this be due to 
Ihelr mechanical or tlieir thcrnpeutic action is the question at 
issue. It is realized to-day. however, that a great part of their 
action is due to the heal thcv contain. 




ria. tfl. — Douclic-ciui fur vugitinl injectiODs. 

Instruments.— The ordinary douche-can is most generally 
used now-a-days. It consists of a can holding 1 or 2 liters (35 to 
70 ounces), fitted with a cock at itii ba.se, to which one can fit a 
rubber tube about 2 meters long (7 feet) and about 1 centimeter 
(2/5 inch) in diameter. 

The Ivfie most universally employed is the half cylindrical 
can with a cock projecting from its .side. This can, generally 

33 



VAGINAL INJECTIONS 



23 



enamelled, is hooked on to the wall on its flat side or made to 
stand on a piece of furniture or even held by a handle. 

There are also forms made for use while travelling; for 






Fio. 17. — Budin'* app»ra(uR, 

example. Itudin's appara- 
tus (Fip. 17). the siplu>n-in- 
Jector (Higginson'ssyrinjje), 
or Doleris" in<Jia-rnljlHT 
bag. 

It is inini'fcssarv li> de- 
scribe Budin's apparatus and 
Doleri-s' bag, so we will 
briefly give the description 
Fi«. 18— Bui.iLi I ,^i : ,L,ciMi.i.i,j..i,.„,v „f ,]',p siphon-injet-lor or 

Hipginson's syringe. Il is a siniplt* rultber IuIm> with a hook- 
like extreniily enabling it to he attached to the side of any vessel, 
and a bulbous projection about its middle which controls the 
amount of liquid passing through the tube according as little 
or increaiieti pressure is placed upon the bulb. 



Ml.VOIt GYNKCOUJGY 

arc usually made of glass, slifjlitly ex]>anded at 
^1^ extrvmitVt nixJ Hnvm^ IuUtuI openings and not terminal 
4W(V w onlcr It) avoid ttic projection of fluids into tlic cervix. 

TVchnlc. It nii;;Iit he tlioiiglit suffit-ient to simply recommend 
» »\>nMn lo tjiko vaginul injections nnd notliing niuro, and tlie 
tf«,n«>nt prartire is for women to make these injections without 
•(«ttsr and uith^mt care and this often results in doing nioi-e harm 
llwn bikmI. An iiijw-tion may result in the introduction into the 




Fto. 19,— (SlftB vaginal i-nnnulo. 

vagina. (vr\'ix, or uterine cavity of septic material, against which 
IhcJif orgiins arc naturally protected. It is of great im(>ortance 
therefore that everything coming into contact with the vaginal 
ravilv should lie aseptic, and the hands shouht lie carefully 
washed. 

The piMtition of the patient f<ir taking the douche is of great 
importance and shouUI Ik.- always dcscriheil in detail to the 
iNilicnt I>y ill*' doctor. Ignorant of the correct method, the 
piiticul sometimes nnikes the injections in the stamling position. 
or M-alcd astride of a i)ath or in a crouching position over a bow). 




FlU. 30. — IW-clipp^T pan. 

llndcr llieM' conditions (he vaginal cavity is almost completely 
firaeivl liv the iilidoMnnal prtvssure and the injection is unahle 
lo iH-tn'Irnte a very little ilistance. so that, if it he employed for its 
i>Hti>rniil elFeet npcui the cervix, a fond illusion is the only result. 
All tnJt-i'lionJt shituld U- taken with the patient lying down, a 
VPM4<I of appropriate form Uniealh the huttocks ami perineum. 
'ritU niMM'UNro the advantages of raising tlic [lelvis and of causing 
llii* VM^lna lo open out. 



VAGINAL INJECTIONS 



25 



II is then freely irrigated and a cprtain quantity of fluid 
reiuaiiiiiig in the cavity forms a sort of prolmij^ed bath of 
undoubted advantage. The can is hooked up to the wall about 
I cm. (20 inches) above tlie level of tlie bed. Grasp t}ie cannula 
''at its base in order to avoid any contact with the free extremity, 
and then release the sto[i-c<>ck on the tubing so as to drive any 
air out of the tube and to get rid of the first flow of water wliich 
is cold. The cannula is then inlrt«lnccd into the vagina, and 
directcil at first backward, and then partly release the stop-cock 
so that the lotion is slowly allowe<l to run. Then rotate the 
cannula in the vagina so that the posterior, lateral, and anterior 
fomices are successively washed out. If the vaginal orifice 
contracts and does not allow the fliiitl to cscjipc. lightly press 
down llie fourehette with the cannula, so- as lo cau^«c the vulva 
to partially gape. 

Having finished the injection, ask the patient to lie fiat on 




PlO. 31. — Double rurroDt Qariniilti (nr very hot viti^iial irri^ution*. 

her tuick for about a quarter of an hour, or if she gets np imme- 
diately ask her to cough or bear down in order to evacuate the 
H vagina of its contents which would slowly trickle away and wet 
her chemise, did we not oljser\'e this precaution. Wipe the 
external genitals with a clean towel or absorbent wool. l*ut the 
cannula in a vessel containing corrosive sublimate I per 1000 an<) 
replace the rublier tubing in the can. which is covered with a 
clean towel. 

The quantity of Huid injecte<i is about 1 to 1 1-2 liters (35 
to St ounces). The temperature should be about that of the 
body. In certain eases it may be necessary to order verj' hot 
injections, about 48 to 50"^ (144 to 130° Fahrenheit), and it is 
noticed Uiat while these are well tolerated in the vaginal cavity 




26 



MINOB GYNECOLOGY 



tliey l)urn on running <»ul. We adopt, therefore, certain pre- 
cjiutions. and place on the perineum a sponge soaknl %vil}i 
cold water or vaseline the skin surface well. If these means 
are insufficient, use a special cannula whicli jtermils of a back 
flow through a tul)e and allows no contact of the hot water with 
the external vulva and perineum. The figure adniirahly illus- 
trates the apparatus used for this purpose. This sjiecial cannula 
iit used when it is necessary to usi; large quantities of hot water; 
at Luxeil as much as 60 to 80 liters (105-140 pints) are used, and 
the irrigation lasts about 15 minutes. 

The nature of the liquid employed need not detain us here, 
and it is ancient history now to use the division of injections 
into astringents, alteratives, emollients, and narcotics. 

One is often restricted to the u.se of an a.scptic liquid such aa 
builetl water. Boracic acid, which is <tf such jiopiilar use that it 
is sold by grocers and other tradesmen, has of course no special 
eireet. 

Sublimate.' 1 or -i parts to 4000; copper sidphate. 3 parts to 
KHKI; alum. 30 f)arts to 1000; Labarraquc's liquor, iS parts to 
IWHt; tincture of iodine, 1 or 3 teaspoonfuls to the liter; 1 or 2 
teas|K>unruls of lysol to the liter, and laniodol, 1 part to 100, or 
tiHing a tablespoonful to a liter of wulcr an<I a .solution of for- 
maldehyde I to 10.000, have all been recommended. 

PerniaTiganatc of potash and hydrogen [leroxide, the former 
In a Hlrengtli of 1 to 4000 and tiie latter 3 or 4 volumes, are 
dtrongly nrcommeudeil. 

.'Vjftringent injwtions are also useful: Decoctions of camo- 
mile, walnut leaves or oak bark are all useful. These decoc- 
ttonn have the advantage in that they force tlic patient to 
Iwiil tlie water she uses. The active principle tannin is also 
used and iiboul S grams (4.i grains) are usihI to a liter (3.5 ounces) 
of boiling water. 

Keferring to alkaline injections we can reconnnend 10 grams 
(2JS0 grains) of liicnrlM)nale of sodium added to evcrj- liter of boiled 
water. 

Indications and Contraindications.— Injections for cleanli- 
ne.HS, HO to s[H.*ak, are useless. Used after coitus they are often 

■ Tlui almiiWt ini-tli<Hl U to nul* pftdtM* of comiaivv siiblitnatv nnil » littlr tjin«r(e 
kdiJ to bolp [t tu iliwHilt't', *nd add ■ •oloring mgtaX to nroid error (sulilmulo Oofl Ur- 
Uhc kciil. IS gn. iniliipi Mrmln. 




VAGINAL MEDICATION 



27 



a cause of sterility. During pregnancy in healthy women they 
are injurious in that they diminisli tlu; bactericidHi power of the 
va^nal secretions so clearly established by Dodcrlcin. Kronig, 
and others. In addition, they may even cause abortion in 
exceptional instances. It is not our intention here to advise 
against vaginal injections, but merely to suggest more restraint 
in their usv for purp<>.ses of cleanliness. They are of use in 
women who are wearing pessaries, and in such cases they should 
be continued even during the menstrual period, merely taking 
the simple precaution of giving them under gentle pressure 
and luke-warm so as not to excite uterine contractions. In 
auch casea avoid the eniptoymeiit of drugs that might become 
de[iosited on the pessary' and render it rough and irritating to 
the vagina. 

As therapeutic agents injections have many indications as we 
will see further on in the treatment of vaginiti.>i, some forms of 
metritis, and even of certain chronic periuterine inflammations. 
Hot injection.s with their vasoconstrictor action are indicated in 
all hemorrhages, metrorrhagias, and menorrhagias. There is 
reason to suspect their action in pelvic suppuration in the acute 
stage and in recent periuterine exudates, because they may 
determine an aggravation of the pain and of preexisting troubles. 



2. Vaginal Medication. 

Intravaginal medication in the form of api)lications i.s gener- 
ally made after the speculum has been applied; i>erha[is as 
brushed out witli (solution of nitrate of fiilver, tincture of 
iodine, etc.); perhaps as an insufflation (iodoform, alum, etc.); 
or as a tampon. For the last-named kind of application, by far 
the most employed, use a tampon of absorbent wool fastened 
to a stout piece of thread which should be of sufKcient length to 
lie between tlte li{><> of Uie vulva, so that it may be drawn out by 
the patient at any time without recourse to the medical man's 
aid. The lampoii. having been sterilized, may lie a vehicle for the 
)plication of drugs in solution, ointment, or powder. After 
iking the tampon in the solution to he used squeeze out the 
8U|>erfluous fluid so that it does not kcTp trickling away when unce 
the tampon is in position. The most varied applications are 




28 



MINOR GYNECOLOGV 



tiKed, and of tlic-se glvceriiie deserves s[>«ciHl mention. Intro- 
duced into gynecological therapeutics by Marion Sims, it rapidly 
demonstrated the jmssessiori of a special action. Eagerly absorb- 
ent of water, it excites an abundant a(|ueous flow, a sort of sero- 
mucou.s emission, and thanks to its hydragogue properties it is one 
of the best vaginal applications. It is use<l pure or witli such 
agents as iodoform, 1 to 10; ichthyol, 1 to 20; resoreine, 1 to 10; 
acid lactic, 1 to 30, etc. 

In order to permit patients themselves to introduce therapeu- 
tie agenbi. we a*lvisc, sonietintes, the use of solid ovules with a 
glycerine base, which dissolve in the interior of the vaginal canity. 

Guinard has praised calcium carburc io cases of inoperable cancer. 
Having cleariril lln- piirts. h picc-t- of cliloriilc of (-iilt'iiiiii is inKcrtcd into tlio os 
uteri and a tampon immediately introduced. The tampon is of iodoform 
Kau/v. After two or thn-c ilnys remove the tuni]K>n. The curhiireof culciiiin 
is reinserted according as may l»c necessary. The method does not appear 
to have found many adhen-nU.' 

3. Tamponing of the Vagina. 

The tamponing of the vagina has many indieaticms: 

(1) Application of an external a[ipIication to the cervix and 
to a part of the vaginal mucous membrane. 

(2) To maintain in tlie uterine cavity a solid pencil or bougie 
of some medicinal subshmce or a laminaria lent or a drain. 

{3) To support a uterus which tends to prolaftse or the reduc- 
tion of a uterine deviation produced by manual manipulations. 

(4) Arrest of uterine lieniorrhage. 

(5) As a means of reducing certain inflammatory conditions. 
The first two ca.ses of the tamponing will require no ex[)Iana- 

tion; but we consider them as coming under the heading of a sim- 
ple vaginal dressing whicli wc have desiril»eil under medication. 
It is (juile ditfcreiit wlieii plugging is done for uterine lienior- 
rhage. It must be done according to certain rules if we wish 
for sue<ress. We observe the same rules as in cases where we 
wish to support a uterus tending to proIai>se; that is to say, we 
endeavor to get a stimulant actiiui an<l to hasten the absorption 
of periuterine exudates. Tamponing for this latter was recom- 

' Uvet, Tlie KinpluymeDt of Culotuio Carbure in Surgery. Tk. de Pari), 1889-06. 
No. 403. 



J 



CATHETERIZATION OP TUK UTERUS 



30 



I 



mendefl in the United States hv Taliafero. and is often described 
under thi* natni.* uf ooluiimixalioji uf Uie vagina. 

Is the action of this agent as extensive as one would like ? 

We venture to afru-ni that it is, but us it is a method of Ireai- 
menl. i neon testa biy anodyne, it can be tried in patients witli an 
enlarged iitrriis witli less true salpingitis than rcmnimls of peri- 
toneal exudates, described as Douglassitis, troubles insuffiflent 
in themselves to demand an operation of removal, but nevertheless 
giving rise to pain. 

'HiLs plugging is earned out in the following manner: First, 
place a targe tanipoti in the |)Oslei'ior fornix and then suecH'Ssivety 
smaller tampons in the anterior and lateral foriiices. These tam- 
pons should fill n|) the fornices and he on a level with the external 
OS. Tliev should be finnlv rolled and comiMict in order to com- 

r I 

press well. Their being placed in position is the most important 
part of the columnization ; this is carried out by filling the vagina 
entirely with tampons moderately compact. In order to pack the 
vagina use tampons of wool and gauze impregnated with glycerine 
and dusted with iodoform. 

Rt*.striclet) to the above typed ease and metbndically applied, 
sueh columnization may give good results, and any patient with a 
retroflexed uleru-s, who cannot put up any longer with a [)essary, 
will be able once more to wear one after the lapse of a var\'ing 
interval during which this methodical plugging of the vagina is 
carefullv carried out. 



4. Catheterization of the Uterus. 

Instruments Required.— Uterine catheterization nr hyster- 
ometrj- can W curried out with simple urethral bougies or special 
Itrnments called sounds. Gum elastic urethral bougies may 



Fio. 2S. — HftUeiiblo sound without index. 

used in sizes from 8 to 12. Sounds may be rigid or, better. 
malleable. The body is usually HlH>ut l.i cm. long (6 inche^s) 
witli a smooth olive tip. mounted on a narrowed neck and having 
a fluttoned anterior surface gra<luated with centimeter indices. 

The indicator fitted to most sounds is to our idea useless and 





I 



pi-eseiits no advanlaf^ 
soever. 

Technic.^'L'he employment of the sound should always be 
prrci.tle«t hy u ttimanuat examination, and we can thus determine 
the dirwlion the sound should take by ascertaining tlie exact 
poedtion of the uteni;!. 

"I'W sound may be introduced resting on the finger or through 

« speculum. It .should be introduced very gently. Generally at 

» Ue{>th of altuut 4 to 5 cm. (4/5 to nearly 2 inches) the resistance 

«CUir i-ithmus is felt. Having passed this point, the sound glides 

Utt l» the funttus which, riitrinally, hardly .sensitive, may Ije pain* 

MiMtferi&tn inthnnniatory conditions. 

ft X*« Attach a dn'ssiiig forcejw to the .sound at the level of 

■ ikBtBAmtal o-t: then withdraw both di'essing forceps and sound, 

^untilWWfcsy to meu.sure otV the depth of the cavity of the uterus. 

^^P WHever the means employed, it is important to observe pre- 

^Ui'lt as the alMolule a.sepsis of the hands and the sound. 

exaniiniition as a preliininury to ascertain the 

laftiMitkxi uf the uterus, and extreme gentleness in the 

ilv iaiamntatiuns of the vagina or cervix contraindicatc 



suspicion of pregnancy is an absolute contraindi- 




I 
I 



dMW pnH'aulion.s many complications which 
iv beaverled. such as pain, colic, abortion, peiv 
^irtkL' t.\tm|4iciitinns. 

W iutrotiuclion of the uterine souud may be 

tjte situation of the uterus, to ascertain the f 

.^ m^^abyieal comlUions of the uterine cavity 

. and fuially to nieasun- the depth of the 

w tftlcwlucv it H-s a preliminary to tlie intro- 

•MiteUl onier to find out to what depth and 

.jwukt W entered. The normal depth is 

tttfi 1/3 inches) in nullipara. G cm. to 

i V S inches) in mtiltipHra, and may be 

\ in metrilix. 8 to 10 cm. (3 1/5 

xulution, and \5 to 'Hi cm. (6 to 



DILATATION OP THE UTERUS 



31 



Only the metallic sound can give pasi'tive information regard- 
ing the direction of the ulern». In a general way this way be 
determined by the bimuniial examination, but there are cases 
where the sound is a great helj) to the diagnasis, as, for example, 
in a uterus with a fibroid in the anterior wall simulating an ante- 
flexion of the organ (Figs. 23 and i4). 





Pio. 23. — Uterine onlf 
floxion. 



Fi«. 24. — t'ibromk of nntcrioT 
uifiriiKi wnll, iiimiilniinK. during 
I»tipBtiou, A uterine aaUHexIon 
(tec l''i^. 23). DiAgnoois woa 
mado with tho Hiund. 



The sound enables us to diagnose a stricture, a partial or com- 
plete obliteration of the uterine cavity, or an intruulerine tumor 
such as fibrous polyp. 

The information wc get, in such a case as we have just cited, 
by the use of a sound is always obscure and incomplete, and only 
intrauterine |)a!pation can give precise information. 

We may use the .sound to reduce uterine displacements, re- 
volving the instrument in the uterine cavity. 'I'liis is now-a-days 
very rarely done. 

Tn short, the uses of ihe uterine sound, at one time regarded 

very many, arc now-a-days very restricted and of much less 
importance than was imagined twenty-five years ago.' 



5. Dilatation of the Uterus. 

There are two varieties of dilatation: ra])id and slow. 

t. Rapid Dilatation. 

Instruments. — Ra[iid dilatation may l>e accomplished %vith 

dilators or graduated bougies. 

■ We dfffpr rprv uiikty from Huguicr, who iii Rnishine liix a-ork uid: The uterine 
■ound will Mme <Uy oc<Qupy n ptucc in Ihi^ dJuKnoiiii of iitrro-ovnrinn trouhka thnt 
•iMcnlttttian and pnrcuwion occupy ln-<liiy in the diagnoiia of cardiac anil uheat com- 
pUnU. D€ t'hgiUromitrit el da auhitiriame uMnn, HuEUier (P.>C.). 




32 



MINOR OYNECOLOCV 



Varieties of ulcrine dilators are many. Tliese are those with 
two or three bla<ies. ami some of tliese have a series of transverse 
grooves on the external surface of the blades, which |)rcvents slip- 




Fio. 25.— Dilator witk two bliidw. 



ping and enables them to cope witli tlie elasticity of the uterine 
muscles. 

To the dilatation of the cer\'ix, which is obtained by these 
dilators, many gynecologists prefer progrcs.sivc dilatation by a 




Fio. 26.— Diklor with three blades. 



series of c}'lindrical bougies, of wliich tlie best known type is 
that of liegar. They are made of hardened gum or better of 
metal, and their length exclusive of the handle is 12 to 14 cm. 




Fio. 27. — Dilator nith lr&n«ver«e grooving on the axt«nial eurf»ue of the blades. 

(abont 4 4/5 to 5 3/5 inches). In order to diminish their 
number, we recommend the do)d)Ie variety; that is, two 
bougies of successive sizes united in one by their bases (Fig. 29). 



Lrll.a .(Jill. 



T-^^ 



Fio. 2S. — Hogar's housic. 

The diameter of the bougie is 1 to 3 mm. and increases succes- 
sively 1 nnn. in each bougie. 

("oilin has recently ]jroduced cylindro-conical bougies which 
arc easier to introdvK-e than Hegar's. 



DILATATION OF THE UTERUS 33 

n dilator or Itougio is used, one slicuilcl be provided with a 
tenaculum foi-ceps for grasping and drawing down the cer\'ix 
ami also with a uterine sound. 

Technic. — The intestine is emptied the day before by a laxa- 
live or enema; the vagina is washed well with soap and irrigated 
witli an antiseptic solution such as 1 in 3000 sublimate. 




Fio. 28. — fJegfU-'s double bougie. 

As Die dilatation does nut take long, chloride of ethyl is sufB- 
cicnt. and one should only have recourse to chloroform or ether 
if it is imjHWsihIc to obtain sufficient relaxation with the first 
uaiuvd. 

In \'irgins. the index-finger must Iwgi'ntly inlroduceil to avoid 
(earing the hymen. Having reached the cervix glide the tcnacu- 



* 



m 



Fia. M. — CoUin's cylindro'CODical bou^c. 



turn Forccgut along the finger and draw the cervix gently down 
to the vulva. When the hymenal orifice is small, the tenaculum 
foreC|>H may l>c guided lo the cervix by a fingt-r placed in Uie 
rectum. In a married woman llie cervix is taken hold of after 
pressing down the posterior vaginal wall with a Sims' specultini. 
Having got the cervix down to the vulva, determine with a 



I 



Fio. 31.— rropurcJ latniuariA. 

sound the direction of the uterine canal, and the knowledge Ihus 
act|uired helps greatly in the introduction of the dilator. 

Introduce the dilator gently into the os externum. If at the 
level of the externum a resistance is felt, don't |jress on, but 
slightly withdraw the inslruuient and reintroduce in a direction 
where no resistance is felt. It is always dangerous to force a 





34 



MINOR OYNECOLOaY 



dilator on because one may perforate the posterior wall of arT 
anteflexeil nteruti. 

Having introduced one instrument, the cemcal canal is in a, 
sense ditate<), then the inslruincnt is rotated a littJe in order to < 
dilate another part, and so on until the whole circumference has 
hcen dilated. Il is then withdrawn. 

The next size is introduced and so on wc continue until the 
dilatation is o(iual to a diameter of 1 cm. (4/3 inch). A greater 
dilatation may lead to tlie laceration of the cemeal canal. 

With hougies the procedure is the same and done with the 
same precautions. The huujrie is well lul>rical4-d anil is intro- 
duced slowly without forcing and with slight rotatory movement*, 
when the pressure of the uterine walls is fcjt. The as internum 
often is veiT resistant, hut it is overcome by a gradual pressure 
on the instrument and by modifying more or less its direction, 
at tlie same time being vory careful to avoid sudden pressure 
which may lead to a perforation of the uterus. 

Kucli bougie is left in ])osition an instant and rcfilaced I)y the 
next number above it. It is imjiortant to introduce each inslru- 
nient and not inLvs any with a false idea of saving time. 

If a bougie cannot be introduced, replace it by the preceding 
one, and leave it in some scconits. I'lic tissues gradually acf'om- fl 
modate themselves nnd with a little patience tlic recalcitrant 
bougie will be found to enter (juitc easily. 

2. Slow or GTadusl DUatatioa. 



Instruments Required. — Formerly gradual dilatation was 
produced by the progressive accumulation of little tampons of 
iodoform wool bound together or by the introduction of prepared 
cones of sponge, but now-a-rlays use laminaria tents, which one 
can obtain anywhere already prepared. 

These laminaria tents are pre-^ervetl in iodoform and ether, 
which has tJie double advantage of pruti-cting them from the 
hygrometrical influence of the air. and of slowly impregnating 
them with an antiseptic. It is important to have a series each of ^ 
different calil»er. A great number are sometimes preserved in one fl 
Imttlc hut this practice is disadvantageous in that it is difficult 
to identify a laminaria t<'iit of the size we want and there is 




DILATATION OF THE UTEHUS 



3S 



8 risk of infwting the others from an instrument imperfectly 

sterilized. 

The manufacturers have striven to prepare sterilized 1am- 
inaria. which are i)ut up in sealed tubes containing a little 
vaseline in onlor to facilitate their introduction. The instruments 
luired arc a speculum, a tenaculum forceps for traction, a tent 
introducer, and some tampons. 

Technic— First determine the position of the uterus by a 



Pig. 33. — The Uuniiurin liu been 
nil Introdueed into Uie utArias 
ckTity sad protrudM from tbv ex- 
tmuil en. II tins auei'eMtively dt- 
UlrdlUio'ocriix and body. 



Km. 33. — The lent in sufficiently 
introducodlisssiiecwt-dcd iuilllittiiiK 
merely ibe cervical cftiial lo grenl 
dinieniionit. 



P bimanual examination or even by using the uterine .sound. The 
liiminaria tent, if too stiff, is ]>lunged into a hot solution of sub- 
limate and is given the necessary inflexion already ascertained 
by the preliminarj- exann'nation. 

■ Having done this the speculum is put in place, the tent seized 

■ Pia.M 



> 



Pra. M.— Tlie InmlnariA prtwed in an nnieUpxi-U uterus, hiu, in dilnlinB, perforated 
tlK- pontfrior lip of the cervix. 

in a tent introducer and is gently pas.sed into the uterine cavity. 
The extremity should go well past the interiial os, and one can 
hardly feel satisfied if a laminaria stem has penetrated hardly 8 
or 4 cm. into the uterus. 





»3DK t;YnStX>LOGY 



it 



c^ 






llta; I 



'itsiakc fnnfuvadv nuitW by beginners, esijccially in 
UM^tritiis cui»(s aetitiupanied by enlargement of tlie 
•ai. 

iiifcaria iwaelr&tes to a certain depth, and then the 

- aB^;a twtstauKV eaiise*! by the as internum eoines to 

■ 'ikWt h* i* ilealinj; with a small uterus and dilates 

'. psotion. It is always of use to ascertain before- 

vkf^dk uf titM' uterus by catheterization with a soft hon^ie. 

kwt teEUK i^ace, put in two vaginal tampons to retain it. 

Ikw^ g#(fMtinwalii>4jiitety essential for the patient to remain in Ixil. 

'|'WiMtl%MilH'tioii of the tent is quite easy when its correct cali- 

Wt iw**! vi*n"f have l«t'n ascertained. 

Al litttfs its removal may present some difficulties. These 
HMO* iUTiM- pushin>; in the lent too far. Its extremity beinjj invisi- 
W«\. iH.<te«d of seizing; it directly and drawinj; it out the tape is 
M^trtl tw. 'I'his should be lying in the vagina. 'I'lie ta[)c breaks 
MH«1 tlw Irnl remains imprisoned in the uterus. The case may 
UnHvine more complicated when, for example, in a strongly ante- 
rt^^xtnl uterus u tent too forcibly introduced into its cavity may 
liHtd to perforation of the posterior lip of the cervix, as a result 
i\f pressure and then comes to lie in the vaginal posterior fornix. 
Incision of the cervix may be nccessarj- in order to extract it. 

Quite frecjuently it is the custom lo combine slow and rapid 
tiilalioii. Having obtained with one or two successive tents, a 
rvlntive dthitation and a relaxation of the uterine ti.ssues, bougies 
arc intr»Miuced to obtain sufficient dilatation for the insertion of 
a linger. 

Indications.^ While in America the rapid dilatation is pre- 
ferred, we believe that in the majority of eases the slow dilation 
i.s the most satisfactory. 

It exjMJscs the ut^'rus less to tears and perforations, and ill 
addition presents some definite advantages. 

Dilatation by laminarja lasts longer than that obtained by 
dilators or bougies. In addition, it exercises an important tonic 
action on the uterus, reiulering the tissues more relaxed and 
su|)ple. Kapid dilatation should be restricted to those <-a.ses 
where dilatation of the uterus is a matter of urgency and to com- 
plete the slow dilatation already obtained by tents. 

Uterine dilatation may be done with the object simply of 




IXTBAlTEItlNE MKDICATLOS 37 

diatjnnsig in ortU-r to kv\ the liniiig nuMiihraiie of the uterus, or 
exce[>tionalIy for an endoscopy. It is mainly <Ionc for tliiTain'utie 
pnrposrs. It may in certain <'ascs form the Iiasis of treatment, 
I, for example, in strictures of the cervix, of uterine dysmcnor- 
lea. nn<i of sterility. Generally it in merely tlio preliminary 
but indi»pen.sal>le part of another operutiou (uterine curetting, 
removal of a polyp, etc.). 

6. Intrauterine Medication. 

Under the generic term of intrauterine medication is included 
lavage of tlie uterus, the application of jiiedicated hougies. intra- 
uterine cauterizations, injections, drainage of the uterus, vapori- 
zation. 

I. Intrauterine Lavage. 

Intrauterine lavages enable us to introchice a considerable 
current of fluid which, apart from its antiseptic action, which 
is variable and depends on the natuix- and quantity of the anti- 



PlO. 3S.— Plimrd's CKtIivtcr. 

septic employe^!, exercises also a mechanical action on the con- 
tents of tlie uterine cavity ([jiucental debris, products of secretion) . 
The operation may be carried out (1) in the puerperal condi- 
tion; ("i) in the nun-puerperal condition. 

a. Jniriiutcrine iMvaije iti thr Pufrpfral StuU: 

Instruments. — We require a bowl, a pair of volsellimi or 
tenaculum force|iei, and a cannula. Inmiediately after the 
accouchement, when the cervix is widely open, we may use the 
vagiiuil cannula, or I'inard's glass catheter. At a later stage it 
will ite necessary to use ii speciid cannula of which various models 
can be obtained. .'VII should fulfill two conditions. 



i.\^A:Ui.OtiY 



. ...- >..;vw^a. >■« Aig^tkw bent in order to easil; 

^ -sdHMuA "j% ui the double-current varietj 

.... . - Ti-.-.^-!'-*^ <J< tluiil to proceed simultaneously 
«^«au. -v iiM, t>)ims* instruments are generall; 



o 




^ 



'i^. 3$. — Budin's catheter. 



S. «,xM>i. iiS*>*- 



„ .^,_. Bttvlin's catheter is very simple. It consist 
x " **^V W v\'«\vvi«jr fluids into the uterus. This tube i 
*vv*\Ni .v**i t*o <t^H»w serves for the evacuation of the fluids. 




Fio. 37.— Dol^ris' catheter. 

IVJoris* v-wllu'ttT consists of two arms, each of which serve 
as A v\«iimI fi^r the introduction of the lotion. It is introducei 
v'tw-it'^l, ami oiK'e in place one manipulates the small screw an( 




Fig. 38. — Boiemann's catheter. 



tluis st'imrates the two arms, in this way widening the cervica 
I'HimI mid creating a way of escape for the fluid. 

If llu^ uterus is small, we may use Bozeraann's catheter 
di'scrilM'd in German text-books under the name of Fritsch. I 



1. NT HA UTERI SE MEDICATION 



39 



consists of tM-o tube.H, one contAincd in the other, the smaller 
scr^'ing for the introduction of fluids and tlic other for tlieir 
evacuation. 




Flo. 30. — Tlie cttUiottr haviiiK bcon iiiiriniiiPtHi into ihi- .irn\, rrHitiUiiice at A ia 
mot Willi tiy ri'ikMjN u( lilt.' BnU'tk-vioti nl iln^ iHi'iiia. 

Technic. — The catheter .sImuUl he introdua-d through a, 
speculum havioj; first drawn down the cervix and fixed it. 

It is important to reineinl)cr that normally the uterus is ante- 




Flo. 40, — (Vvsler.) Tho upprr Iwo-lhirds o( the ulerus oro ia a stulc of roniraf tion, 
Tbe MtUietor in««U with realHtanc« at the pNcudo^phinctor, AC, ourrt^tiiondinit la the 
biMior put of tlio contracted ■one. 

flexed and if one pushes on straight ahead after having engaged 
the catheter in the cervix, there is always a risk of perforating the 
posterior wall (vide Fig. 39). It is important also to remember 





thai after the accouchement atitl <lelivcry, the uterus retracts 
unequally; while the two upper thirds contract forniinf; the };lnl>c 

■BO well known to all accuucheurs, the inferior segment and the 
cervix often thin out and become soft and flabby. It will thus 
be seen how easy it is to introduce? the catheter into this lower 
segment and not be able to wash out the u])per two-thirds at all 
(Fig. 40). 

B It is important to observe the rules for tJie introduction of the 
iustniment- Once the catheter has engaged in the cavity of the 
cvrvix, straighten the uterus by placing the left hand on the hypo* 
mstrium and depress it. Then lower the free extremity of the 
catheter (as in the diagram) with the riglit hand, and the instru- 
ment is then gently introduced into the uterine cavity (Fig. 41). 
The hand on the abdomen has reduced the anteflexion of the 
ulems and in order to introduce the instrument into the uterine 
csritv. deprwis the free extremity in the direction of the arrow. 

Iii the catheter is stopped by a uterine conlraetion. press upon 
thri*seudi»-.*p!iincter thus created, with Ihe finger, and tlie catheter 
viU i^i^\v without difliculty li> the ftiii<ius (Fig. 4^). 

V Uiiht pn-ssurc of water is obtained by raising the douche can 
M Id 40 cm. (14*— 10") nnd this sufliees for flushing out the 
V strong pressure might lead to the liquid pene- 
iJir uterine sinuses, Usually 2 to 4 liters (70 to 140 
, arr sufficient. Finally give a vagina! injection. The 
is. micfllcti two or three times in the twenty-four hours. 
— ^ Mbvduction of the cannula may give rise to certain 

'Ibrvfvix being very soft, it may !>e impossible to distiu- 
■T»inii«l will-"*- 't "'" '**' necessary in such a case 
il fingers, 
in^v Ik' contraeteil and llie os closed. To 
^•miwx some of lb-gar's dilators, 
^v be Hexed or deviiited and then we must 
.^jlt wirllum forceiw. 

Iw\f used, in certain eases, continuous 

|o-4lay has been al>andonc>i] but ha.^ 

• meases of (vrtain rare forms of pseudo- 

. ipr<riti.4. 

jMHttnuous irrigation, we must ha%'e a 




K 



rf wilh a spring iiiatlress. Place on it two mattressps, oacli 
folded on iUuIf utid st'i>aralo(l so as to leave a space fall in the 
middle of the bed. Cover each mattress with waterproof or 
some ini[)cniu'al>Ie material and so arrange Ihe free extremities 

tof the same that Ihey meet in the free space in the middle of the 
bed and direct the lluid into a receptacle heneath it. 

The reservoir nsed may he of glass or of china, and should 
hold about in liters (700 ounces). It is raised about 50 cm. 
(1 1/i feet) above the bed and fitted by a rubber tube to the 
catheter (Kig. +3). 

Complications. — A scries of cotiiplicatioiis may occur during 
an intrauterine irrigation. 

1. Perjanttion of the lUcntx. — This may occur at the level of 
the inferior segment, perhaps, when force is used to c)vercome 

^ no. 43.— Amnswnebt of tfae bed (or mntinuouii uriKution (Pinonl aoiJ Variii4«). 

\)k resistance or may be al the fundus, if the uterus is very scpUc 
« ii \l has lost its tonicity. 

i. VauXtni'ttm of I'luul into tite Peritoneum. — To avoid this 
i\v«n me a light pressure of fluid. 

S. Iilroiuritofi o/ Fluid or Air into Hit I'mM.^It is a matter 

^^nAGKcnot to flush out with nnythlng of a toxic nature during 

^ntita^ but to our mind it scculs an exaggeration to fear 

^^KiVjitogen peroxide during the four or (ivc days immc- 

■•^ ^■^'ui^ » accouchement. Itccause of the sinuses not 

T^t'^^jiSAj dosed and the |K>ssibility of gaj( bubbles enter- 




ISTRAITEBIXE MF.DICATION 



43 



4. Xervous Complications.^^uch ner\'ous complications as 
shivering, dyspnea, cardiac distress, syncope, convulsions, etc., 
are still imperfectly explained. If these occur, withdraw the 
cannula, lower the patient's head, and carrj- out the treatment of 
shock. 

Secondar)' complxcaiunis of intoxication, due to the absorption 
of the antiseptic employwl, have Ik-cr cited. 

Indications and Contraindications. — Intrauterine flushing out 
has two main indicatiuns^lieniorrhu^c and septic infection. 

To combat hemorrhage, first curette the uterus manually or 
digitally, and then inject from 3 (o n liters (10.5 to IT.5 ounces) of 
sterilized water at 48° Centigrade {1^5° Fahrenheit). This will 
produce a hemostatic retraction of the uterus. 

To combat sfptie infection accompanied by fever or retention 
or fetid lochiH, the irrigation should be carried out with water to 
which iodine has been added (1 or 2 teaspoonfuls of Fi-ench tinc- 
ture of iodine (French Pharmacopeia tincture of iodine is 10 per 
cent. ; B. P., i 1/3 per cent,) to Ho ounces or I liter of water) or 
witli permanganate of potash 1 to 1000. or with chlorinated water 
(3 tablespoon fuls of the "liqueur tic Kabarraque" to the liter) 

I or with hydrogen peroxide 5 volumes. 
The intrauterine injections are conlraindicated in rupture or 
pci 



perforation of the uterus, even when only suspected 
a previous injection has produced nervous complications. 



b. Intrauterine iMvage m the Non-jmirperat Slate. 



or if 



These injections are generally carried out after a preliminary 
dilatation. A red rubl>er urethral catheter may then be used, 
and of course tlie customary douche-can. 

If the uterus has not already been dilated, we have recourse to 
one of tlic s[H-cial instruments such as the combined ililator- 
injector of .\ug. Reverdin or that of Jayle. As the arms of the 
catheter arc applied to the right and left sides of the uterus, tliese 
parts are not well irrigated, so it is as well to have another form 
of the same instrument in which the blades open perpemlicularly. 

In this manner by the alternate employment of botli forms, 
we can be assured of a complete irrigation of the uterus. 

Tlic most varie<l solutions are employed, such as 1 to 2000 



belt IV 1 1 
fol'l. I 
nil 

SOItK 




sablimatc of iiicrt-tiry^ 
i fhloridi. 1 to -iOO; 



.-.-■r!:Ain is that the sohition 
■ uterus. 
-.1^ irrijiatiou siiiiihir to those 
^.^ state, hut tiiey arc nni(;h rarer. 

bijections. 

, lia^'e been recommended by many 
i( of metritis. We may u.se the 




fc —.V tt«v«nli»'* comtuned ililatinit and nu^thintc cathotor. 

._.„ ^^ I M^utioiis : Silver nitrate. 5 to M per 1000; prolarj^ol. 
,„^ ^ef HW(>: chloride oF zinc, .'i to 50 per 100; copper sulphate. 
VI- h*0.|»er<'hlondeof iron, 50 lo 100: tincture of i<Kliric, 30 
I*, iw, ,*fcth\»J. I'l""*-' or combined in etjual pjirts nith glycerine. 



IE 






^■t<i. 4.V— limiiti's •ytingfi 

Those irrigalion.s must I)e made always with a well dilated 
ivrvix and only a snudl quantity of solution introduced at a time. 

To carr\' the injet-tion out, in Germany. Hraun's syringe of 
hanU'iied ruhher is used. One can also use the syringe. 

If a caustic solution is used, as a preliminary measure put a 
tampon of wool behind the {'ervi.\ in order to protect tlic vagina. 



INTRAUTERINE MKUICATION 



45 



These intraiiterint' iiijectlon.s are not alwiohitcly Iiarniless. 
Menj;e has collected thirty instances of death after the use of 
Braiin's syringe. Deatlis liave occurred after its use in doctors' 
coiisuUing-rooms or even in the street, when the |>aUenl is relum- 
ing home. It can he understood wluit a coininolion such acci- 
<lents wouhi cause, following on a treatment considered l>y the 
family and friends as absolutely simple — used only to give a 
liltlr relief. 

These accidents are occasioned by the penetration of the solu- 
tion into the tubes and then into tlie ]>eriton(>al cavity and this 
[H'uelration has been experimentally demonstrated by such men 
as Doderlcin, Zweifel and Menge.' There is, therefore, good 
reason to abandon these injections. 

3. Application of Medicated Bougies and of Caustics to the Uterine 

Cavity. 



Aledieated hougies or pencils which are introduced iido the 
_ uterine cavity are formed of a paste-like material. (|uite firm at 
P ordinary temperature, hut which softens in tlie uterine cavity and 

then is lilieratcd from this pasty material the active ingre<lient. 
JK One of the most fnxiuently employed is the iad<»form pencil 
I or bougie: 

r thai . 



B. — Iodoform, 
Gum arabic, 
Glycerine, 
Ainidon, 

For 1 penciJs. 



aa 



20 granis=.5 drams. 



i grains=30 grains. 



Pencils of ichlhyol are frequently used. 

Caustic PencUs.^One of the mwt frequently used forms is 
thai <if Ifitinoiitjtnilii'r confmnrd in Canquoin's paste (chloride of 
zinc 1, rye iluur'Z). The pencil weighs 1 gram (1.5 grains) and is 
surrounded by a piece of tin in t)ie portion which would lie at the 

' Dod«tlcta. before dcint; vagiaul lijiicrcui.DiniPii, mitde a BCrieA of inirauterine injec* 
Uon* intli enUiiiu unota ftnd dotmiiinfd tlurowitli tho immodiftte proiODCG of thoc 
wilutJoiM ill the tiibe4 and peritoneal cuviiy, .^u uliji-cilon na* rajwd to thi*. vix., ilutt 
thd* peaetiBtion wn* due to manipultttjoDB of tlie utvrua during the eoun» of the openi- 
UoB, Iloirevrr. '/.nvild eind Moukd have ob*orvcd tKe nine ooounenees in abdominal 
■wtlom end lutvc wcii tbe colored Nolution sppeHT at the opening of tho lubo* witliout 
Miy nunipatelioa of tbe ut«rua at all. 





K Iti: 



internal os. It may he iiitrtKluced into tlie utenifl ami ai\o\v 

ito remain there. During the month following the cauterization, 
it is important to [mss a catlietpr with an olive tip, frequently, 
in order to avoid tlie production of atresia. Numerous complica- 
!ion.H .such as stenosis, obliteration willi amenorrhea and hemato- 
metrn, dysmenorrhea, and troubles in the adnexa have caused 
the almost complete almndoning of these pencils, which enjoyed 
for some time an unmerited vogue, 
ft Silver nitrate pencils are introduced and left in the uterus; 
also those of corrosive sublimate (eornwive sublimate 1, laic 
powder 0.5. tragacanth gum 0.3, water and glycerine, q. s.). 
P All tho-sc caustics, in which one is unable to control the action, 
should l>c abandoned. 

It is not the .same wilb Filhos bougies which are applied to the 
ttiiMrnt of cervical catarrli. Tlie employment of Uiese pencils 
iting of Vienna paste solidified and placed in leaden tubes, 
has htm [Ktpularizcfl quite recently l>y L. G. Richelot. 

A slender tampon of alworbent wool is placed in the posterior 
c: ihe leaden tube is cut witli a knife and the caustic is 
IcNitalHtut half a centimeter (about 1/5 of an inch). Hold- 
dosed end of the tulie in a [mir of forceps, the caustic is 
i for $ome time to each part of the cervix, waiting until tlic 
ibrane thus attacked becomes blackened and begins 
It is applied to the whole cervix and pnrtieularly to 
. 'jar**-, bere and there, where the trouble is most aggravated. 
to time. wi]>e the end of the caustic and lift up the 
rhich covers over the cerWx and continue until 
b black and everywhere well formed. 
bsls frtim 3 to 5 minutes and afterward an 
is placed against the cervix. 
i»cfther .slightly painful or painless; in any case 
tbin) or fourth np]>[ieation. The patient 
, but she should rest in the extentleil [msi- 
d^w-kHift. On Ihe following day she should 
i make one or two injections daily of 



days. 





I 
I 
I 



Koewed ever)- five or seven 
has completely separated. 

varies from eight to twelve. 




DRAIXACE OF THE UTERrU 



47 



Between the little operations if the area dealt with has cicalrized 
completely, the volume of the cervix is reduced and its form 
salisfaclory. 

Probes for Applying Caustics.— *Thesc are numerous and of 
every imaginable form. It would appear to us that the best is 
to use a metallic stem with a flexible end which iss[>irally gi'ooved. 
As a result of this flexibility this probe can follow tlie deviations 
of the uterine canal and reach the fundus, without need for a 
preliminary dilatation. 

Around the probe a thin wisp of wool is rolled, being careful 
to use only one ])ioce, so as to be able to withdraw the whole in 
its entirety. The wool is left in the fonu of a tuft at the end of 
the probe in such a manner that the licjuid cau-stic, Iwing expressed 

■ by pressure against the fundus of the utcnis, can Row over the 

■ whole length of the mucous membrane. The wool rolled around 
the stem of the probe should extend down low enough so that it 
lies below tlie vaginal portion of the ccr^Hx. thus enabling us to 
seize it with a pair of forceps and to be certain of removing both 
probe and wool together. 

Chloride of zinc may be used in 50 to 100, nitrate of silver 
SO to 100, tincture of iodine, pcrchloridc of iron, and funnalin 
25 to 100. 

It is absolutely nwessary for each cauterization lo jwss the 
probe gently around two or three times, As a dressing, place 
a tamjton of iodoform against the cervix. Don't practice cauteri- 
zation loo often, and let eight or ten days elapse between each one. 



FlO, 48. — Probe witJi Bvxible exlreinily. 



7. Drainage of the Uterus. 

Tlio placing of a drain in the uterus is done in order lo 
ioc\t the cavity well o(>en in order to facilitate tlie discharge of 
secretions. 

For tliis pur[}Ose we use glass IuIh's pierce<l with snuill holes 
l(Fehling), metallic lul>es (I<efour), metallic drains (Petit), etc. 



«i:»US GVXECOLOGY 

K XAdL^Ui o< tW« drainage apparatus in the uterus is 
. '.-L. 'w .skNiU^ silk ur horsehair stitches through the lips of 

'rK^i; 'UK,-4i£>unns- of pennanent drainage are contraindicated 
. :v iiv I vi- Uk-iv exists the least inflanamatory state of the adnexa. 
■ ,.('f's\u*>. [o u» to be hardly necessary to state the indications as 
»v luvc never had rei-ourse to it. We have only had occasion to 
.-.v auiJrttiuu^ after intrauterine intervention and then we used 
I ^luple rubber drain which was held in place by a tampon placed 
.i^iuu*t the external os. 

8. Atmokausis. 

I'liUer the name of atmokausis ("i/*o«, vapor) we wish to 
iesi^uate a siHi'ial method of physical cauterization in which the 



1.: 




Pill. 47,^Lefour's tube. Fio, 48. — Petit' s drain. 

cauterizing agent is simply steam. 

First used in Russia by Sneguiref, atmokausis has been prin- 
cipally employed in Germany where it has been the subject of 
numerous works principally by such men as Pincus and Duhrsen.' 

Instruments Required. — Sneguiref simply used a boiler and a 
reservoir for the steam, and a rubber and a metal tube. Duhrsen 
■ L. Pinous, AtmokauaiB und ZeBtokausis, Second Edition, Wiesbaden, 1906. 



ATM0KAU3IS 



49 



I 



introduced into the uterus two concentric tubes, of which the 
external was a bad conductor of bt-at in order to avoid burning 
the cervix. 

I'incus' apparatus is ihc most used. The generator is a 
small boiler capable of a pressure of 8 1/S atmospheres. 
Its cubic contents arc 600 e.c. and it is cv'Iindriciil in 
shai>c. Attached to the lid of the boiler is a graduated 
thermomeler capable of registering up to 120° C. ; second, 
u safety valve which releases the steam at 115°; third, a 




Fio. 4«.— Pincus' appantiix. 

nielal tulie raised to a certaiu height in order to avoid the pro- 
jcctiuti of water Into the nibber tulie to which it is attache*!. 
This rubber tube is specially strong and Is strengthened by a 
woven Ijarid arouiul it. It is connected by a tube with the 
steau) pipe. It is 75 cm. (.SO inches) to 1 meter (39 inches) 
long ami terminates in a sto])-cock with three valves, wliieh 
may close off the Imilcr and permit tlie steam to escape or to 
enter the uterine catheter. 

This catheter consists of two tuU'S, one contained in the 
other. The internal is pierced with small openings along its 
whole length of 3 cm. (ij.*) and it conducts the steam. The 




BO 



MINOR GYNECOIX)GY 



external tube, closed on its convex side, is |»ierced in front 
by three cIongHlcd windows and through these the steam escapes. 
Place on the end of the uterine catheter tips of various forms 
to accommodate to the length and curve of the uterus. 

A cover protecU the cervix. 

Technic. — Anesthesia is not required for atmokausis. Tbe 
cervical canal should, as a preliminary, be dilated by laminaria 
tents or Hegar's dilators. 

Having introduced the speculum, seize the cervix with a 
volsellum forceps and introduce the catheter into the uterus. 
I'usli it on as far as tlic fundus aiul then draw it ba(-k a little 
so that the extremity is free. Then allow the steam to pass 
through. 

If a superficial destruction of tlie mucous membrane is desired, 
such as would be the aise in women <Iuring the period of sexual 
activity, Pincus advocates passing- a jet of steam at 115° C. 
during a very short time, say 5 to 15 seconds. 

After the menopause, in a case where the whole of the mucous 
membrane sliould be de-stroyed. steam at 105° C. is used, but 
it is allowetl to pass during a longer periml of time, that is 2 
to 3 minutes. 

There is an innin-diate discharge of a dark fluid which reminds 
one of strong bouillon. For some days following this operation 
the necrosed part becomes detached and a sero-sanguineous dis- 
charge takes place. It is not at all rare to see an elevated tem- 
perature similar totli.'itseen after an accouchement and caused by 
retained lochia. In event of a ri.se in temperature Husli out the 
uterus with a double current catheter. 

The regeneration of the mucous membrane occurs in the 
same manner as after a curetting if some isles of mucous mem- 
brane have been left. 

Complications. — (_'omplications have been cited as a result of 
intrauterine vajiorizalion, some immediale and some consecutive. 

Tlie immediate cojnj)li cat ions are burns to the vagina, to the 
vulva, and to the external surface <iF the cervix. There is less 
risk of producing these with Pincus' apparatus than with that 
of Duhrsen, which iias no rubber tulw? for the evacuation of 
the steam and allows the steam to go out alongside the catheter 
in the cervical canal. 



SI 



I 

I 

I 



The accidents which occur later are tlie stricture of tlie cen'ix, 
the complete or partial obliteration of the uterine cavitv, death 
by perforation of the uterus,' and infliiniinution extending to 
the diseased adnesa. 

Indications.^ — ^Atmokausis has heeii employed in the treatment 
of hemorrhagic metritis, septic puerperal metritis, fibromas and 
menopause hemorrhages. It has also been used to cause a retro- 
gression of an incompletely involuted uterus, to treat subacute 
gonorrhea, etc. Pinrus advocates it for disinfecting retained 
|)lacenta. 

There is a manifest exaggeration in the indications of the 
method: it is quite certain that when we are faced with a pla- 
cental retention or a decidual hemorrhagic metritis, the indication 
is to empty the uterus. 

Atmokausis a[)pears to us to have tlie great inconvenience of 
being a blind nictlin<l, who.se action is with difficulty regulated.^ 
Dodcrlein and Kronig reproach the method very deservedly, 
because it does not act uniformly on the whole of the uterine 
cavity; their researches have shown that while at Ihc level of the 
point corresponding to the opening of the tube a deep eschar 
i» pro<luee<l. the mucous membrane in other parts is macro- 
scopieally and microsc-opically intact. We believe that it is a 
method which is only allowed to exist, owing to the contra- 
indications of other forms of intrauterine treatment. Doderlein 
and Kronig think that <inc should rightly try it in heninrrlmgic 
endometritis which curetting has not cured, in hemorrhages 
occurring in leucemia, where intervention of a larger order is 
dangerous, in those of diabetes, hcniophilia. WVrilolf's disease, 
or where there is a contraindication to anesthesia and in hemor- 
rhages occurring at the menopause when there Is certainly no 
neoplasm present. 

In. 



. cftw of Van dcr Vcldc »tu\ Tr«ub, Piiicus' ti|>|ianituii wm used. The ttvHin at 
IDS' C. b&d been pawicK uboiil 1 minute. Pi-ritntiitiii lUpprvptird u the result of n prrfora- 
tioa of tlic fundus. TJirrf wiu fniiiiit In hr (oIaI nonrtiran of tho muooui membrane and 
(m BciUtD plaora •uperTiclnl ni.-crot<iN nl the iniifde. 

* Flntau hu maile u sLTies of p.\aiiiiniitiutui of Uteri frcalilv Knlovl^tl■ Ho ital<!ii: (1) 
Tliat tfav t«mpPTaturc indinolprl l>y a llinrmotneler plunstwl tlimiiKli IM utcnni! wall 
ialo Ita cavity vaiM-*tictw<?oii 7uaiiiiS0''C whMitlii.- thermometer uiittii^Et't]i.-TJi1or mark* 
lOS to 1 lO*. (2) Tlial the naulta are exlremely variiiblc. tlip nnicous mcnibrnnes being at 
limtm hardly t9iieh«d, i>Oinetim«« entirely destrnynl, thn inti'nEity of lh« cautciitallon de. 
pcDilinp miich lean on thr duration of thvitlctiin vii|joriraii«ii t)ian theiiae of tho ut«rinii 
cavity, oj tti« anatomical variety of t)ie ini'triUii. of the variablu oont^nU (pwaence or ab- 
MUcw at blood), of the uterine cavity. (I'laiau, .UanaJaeAr./. G«b, m. Gyn., 1899, T. II, 
p-MJ.) 



^ 



7. 



■LisiS.-- 



HINOB CYKECOLOOY 
I'litkr ihU iisnic I'incws tU'sorilw's a method of cautcr- 



'Stttt'j- ■.■ ■.!,> Ik-«i, TK* itistniinerit U introduced into the utc-rus and the 
itiluriur liiily U hcutaxl l>_v a circulation of stt'tim which does not come into 
M-Iuol Lvulact itwir with the uterine tissue. It is emplovcd ui dysmcnor- 
r\ndt Mild iiicuuiplvto involution of the utorus. The re.<uH» pu!>Ii?ihed are 
>(tU t^H) few fur UH lo givf uuv ojiiniou on this form of treatment. 



0. Bier's Method. 

The protiiictioii of local hy]jeremia wliich constitutes the 
ehurui'tcristic of Bier's method for the trt-atiticnt of iiinaniiiia- 
tion i» carried out in three ways. viz.. the application above the 




Fio. so. — Ruili>l]>h'H appnrntus for hot-air iiijVrtioiii. 

discHsH [>arl of a constricting hand, l>y the action of heat, 
an<l by as|>iration. 

'i'lic la.Ht two jiroccdiirc-s liavc been applied to uterine troubles, 
in particular to iuflamtnution of the cervix. 




Fio. SI.^Evrrnmuiiii'ii cupping nppnmtui. 



In order to produtv the therniie action, J. Uudolph' has 
produce*! an appjtralus like a bent Irunipet. The ex[>andetl 
end consists of metal and it is attached by a joint of amianthus 
to the tube portion which consists of wood (Fig. .50), 

The terminal part in woo«l is divided by a septum into two 

' lludolph <J.), Dio Bicr'acho StfMunc in iJ*r Kyoiikoti>gUdi«>n rrtucis. Z*ttr.-BI. 
/. r/yii.. IjHji*i([. IW)5, p, 1185, 



P£SSABI£S 



S3 



I 



partments. The heal gefs lo llie cer\'ix through the lower 
part II, then Hows into Uie iipjjcr chamber b ami goes out tlirough 
a s|>ceial orifice at c. 

If the Clipping ap[>aratus is used the hesl is that of Evers- 
mann,' consisting of a glass cvlinder closed at one end. This is 

f applied to the cemx and by means of a rubljer tube and sto|>- 
cock attached near its extremity air can be exhausted from il. 
na 



I 



10. Pessaries. 



Pessaries are insLi'uments designed to keep the uterus in its 
natund situation. 

History.^In ancient times jiessuries were employed to remedy 
prolapse of the uterus. In place of the apples and oranges which 
were used in the middle ages by women to prevent pn>la|>sc, 
appropriate ajiparatus was introduced to remedy this con- 
dition. In a book written by A. Pare we find a description 
of i>e8saries and their method of employment. Since the 
study of uterine rieviatinns has begun, Neugcbaiier has been 
able to collect 400 ilili'erent forms. Since tlie great exten- 
sion of o|>Prativc gj-necologj-. pes.saries have been almost com- 
pletely given up. Some gynecologists, Kustner in Germany 
and Hantock in England, liave protested recently against this 
ai>andoning of jK-'ssaries, In aehial practice, dot-tors in France 
hardly ever advise the use of pessaries and if they do they content 
themselves with advising the patient to buy a ring at an instru- 
ment shop. If she is advised to have a little operative inter- 
vention, she .sometimes goes directly to the instrument maker's 
who furnishes her with an apparatus the dimensions of which 
are .-(ueh as to render it useless and the appliration is probably 
impro[M-rly made, if she is not taught lu»w. It is (piite evident 
Uiat the floclor Ls wrong in being so disinterested in the pessarj", 
and, although he should not attach so nuich importance to it 
as wax tlie custom long ago, still he should act as an intermediary 
Ijvtwocn tlie instrument maker and the [mtient — a state of affairs 
which would ;tssist the woman gi-eatly. 

The Various Types of Pessaries. — ^Therc are tliree great classes 
of pessaries: 

* EvenniMui (J.), tbulem, p. UflT. 



54 



MINOR GYNECOLOGY 



1. The vatfinn-abdominai pessary is applied in the va^nal 
and is fixed to an external |>art which is supported from the] 
abdomen. 

2. The vagiMil pessaries which are entirely included in tliej 
vagina. 

3. Intrauterine pessaries which penetrate into the utcrinej 
cavi^. 



Fl*. 62.— Borgnefi peaaKTjr. 

Wc will not discuss the last variety as so many com plica tiouj 
may be set up by their use that they have been abandoned. 

Vagino -abdominal Pessaries. 

These pessaries, sometimes called hysterophores, are used] 
to support the uleru.s in prolapse. 

They consist of a pad, a ring, a sort of ampulla which supports 



Fio. fta.— tniufHatiaK bag. Pio. 64. — GauII'B kir ptaaary. 

the cervix and which is fixed to the abdominal belt of various 
forms. 



Vaginal Pessaries. 

Their variety is considerable. Among those most employed 
wc will cite that of Dumoiitpallier, those of Thomas, Hodge, 



PESSARIES 



55 



Smilii and SchulUce, Thu last named lias made a profound 
study of uterine deviationN and their treatnicnt. Patients stitl 
sometimes use, most often on the advice of llicir doctor, the 
india-rubber sphere, which is blown up when once in place. 
This pessary. like all those of soft rubber, lius the disadvantage 
of easily altering its shape (Figs. 53 and 34). 

Dumontpailier's Pessary. — It consists of a sort of walt^h spring 
covered over with rubber (Fig. 55). 



_^ 



Fio. 55. 



Fio. 59. 



Flo. 57. 



I lloilijrs Pe«sartf. —This pessary has the form of n rectangle, 
I nith the angles rounded and is doubly curved (Figs. 50 and 57). 
I Gaiilard Thumaa' Pesmry. — It has the shape of a Kodgc 



I 
y 



PtO. 5S. 



Fio. 59. 



Fio. 60. 



in which the posterior anr is marke<lty thic-keiuil (Figs. 
^ and 59). 

Albert SmiUia Pessarif. — Also the same form as the Ilodgc 
except that the inferior part is narrowed (Figs. 00 and 61). 

These three varieties of pcs.saries act indirectly on the cervix 
by tlie tension of tlic surrounding |iarts. 

Svhullze's Figure^of-H Pessary.— 'Ihe upper loop of the 8 is 
smaller than the other. It embraces the cervix but not too 



66 



MIXOR GYNKCOLOGY 



tightly, while the lower loop, proportioned correctly lo the 
vajfinal ca|>actty. is held by the vulvar ori6ce which prevents I 
its expulsion forward. Tins pessary has a direct action on 
the uterus. Grasping the cervix it forces it backward (Figs. C4'j 
and (i3). 

SchuUzc'i'Sledgt'-formcd Pessary. — ^The sleddt^fornied (>es.sary 
consisU of a posterior portion which embraces the cenix and a 



Via. Dl. 



Flo. 6'.>. 



Fio. «a. 



widened anterior portion which fits anteriorly into the anterior 
fornix (Figs. 04 and 63). 

These different models of pessaries are generally made 
beforehan<l in hardcm><l iiulia-rubber. It is much l>ctter to 
model the pessary on tlie oonforiuation of the vagina. Marion 



J 




Flo. H. 



Fig. «&. 



Sims used to do this and made his with rings consisting of 
alloy of tin and leii<l. Sclmltze prefers rinpi of celluloid which 
soften easily in warm water and then preserve the form given 
them. They have the advantage of being light, smoutli, and 
their polish is not altered by Uic vaginal secretions. 

Mode of Introduction and Details to Observe.— Whatever 
the form of pessary used, coinmeiice by replacing tlie uterus. 
The |}c.vutry u>i-d should be large enough to be in contact with 



iia 

lis. B 




PESSARIES 



67 



i 



I 



the vaginal walls, but not too large so that they are distended. 
It is, as a preliminary, allowed to re^it some time in hot water 
Taselined well and introduced. 

DumontiKillifr's ppssan" is tlic simplest to intrnduee. One 
lias only to bend it between the Ihundi and first finger and 
then introduce the upper part into the jiosterior fornix. Then 
relax hold of it and it will spontaneously take Its position. The 
pessary will be found lying at the extremity of the vagina com- 
pletely .surrounding the et-rvix like a crown. If it does not 
spontaneously find the correct position, it may )je easily mani])U- 
l»t«d with the finger. 

Both fornices being distended, this pessanr immobilizes the 
uterus and maintains it in a good diret-lion, at the same time 
preventing invagination of the vagina and preventing prolapse. 

In onler to make it very etfieaeious in its action the vagina 
must lie sufficiently distended; also it is necessary to clioaic 
n ring whose dimensions are pmportioned to the canal. 

In order to introduce Hodge's pessary it shoulil be ])re.sented, 
so to s[)eak, in the antero-posterior ]>Ianc which corresponds to 
the greatest diameter rjf the vulva. The ring having passed 
llie vulvar orifice one gives the instrument a turn through a 
quarter of its circumference, and then carries it on till its annular 
extremity lies deeply in the posterior fornix. The inferior 
extremity should rest a little Ik-Iow the urinary meatus. 

The abdominal pressure tends to force the pessary into the 
horizontal plane; under these <'amlitions. llie posterior extremity. 
falling down somewhat, stretches the posterior vaginal wall and 
leads to the drawing bark of the rervix and the levering forward 
of the body of the uteruii. 

TTie rigid |>e.ssaries when of correct dimensions should not 
distend the vaginal walls excessively; it is a good [ilan (o be able 
to pass one's fingers between them and the vaginal wall in order 
lo avoid unplea.sant eoinj)Iicati(ms. 

<3nce in place make certain tliat the pessary retains itH 
[KKUlion when the patient stands up. 

Then ask the |>atient to go through a series of movemcntji, 
bending forward and backward, silting down in a crouching 
jKwition, etc., so as to be sure of the {H>s.sary renuiining in 
|>osition. 




5S 



MINOR OVNECOLOGY 



After several days, reexamine the patienl lo see if the [lessary 
is still in good ])0»ition am] doe^ not cnuse any unpleasant or 
painful sensations. The pessary should only jtive evidence of 
its presence by the relief it afToixIs. 

Thus, as the patient does not feci tlie j>essar^', always warn 
her of its presence, and don't allow her to forget its existence 
and leave it indefinilcly iti place at the risk of leading to ulcera- 
tion and even |>eiH'oration of the neighboring cavities. 

Daily injections of boiled water with perhaps, if necessarj', 
the addition of a little carbolic acid, lysol. permanganate of 
[H>tash, are useful lo keep the pessary clean and to prevent the 
accninnlalion of spermatic fluid and secretions of the cervix 
upon it. 

Diiinoiilpallier's pessary should be taken out cvcrj* day, 
washed and replacct] by the patient, but this cannot be done 
vrilh other varietie.s of pessaries which have to be introduced 
by the doctor. 

The great nmjorily do not prevent coitus; their presence is 
not even suspected by the unwarned spouse. 

The duration of leaving a pessarv in place depends upon 
the substance of which it is made. Rubber pessaries not vul- 
canized iK^come altered soon. 

As a genemi rule it is useful to take them out from time to 
time, every one or two months, and examine the vagina for 
erosions of the mucous tncmbrane. which may occur without 
the patient l>eing aware of it. 

Complications. ^A series of cam[j!ications may occur varj'ing 
from the simple calcareous incrustation of the |>ossari' to the 
formation of vesico- or recto-vaginal fislulse, resulting from 
inHammalion and ulceration of the vagina, Cases have U'en 
cited also of inflanHnat<»ry periuterine swellings, and also 
strictures preventing the withdrawal of the |R>s-«*ary, etc.' 

All these complic-ations can .easily be avoided if one takes 
the precautions we have cited above. 

Nous will again assert that we reject absolutely tlie pessaries 



' N'«iutpb*ucr bn* rollc^nl 3(11 cMt* of eompUcntion prodaeed by pcuMnn. 42 vmImi- 
ngiMl natiihe. 37 nctu-vaiciiiftl fistuW. 13 oomliineil Todco- ftnd f«cto-iiM[iii*l fistiiht, 
2 utoTw- vaginal fintiile, I uivrv-VMioo-vuiiuJ llatula, 3 pctforsliofu o4 the urclJira. 1 
fwrtonitioii (it ihr iiiiiall iiilMtine, 4 ncrfontiona of pouob of Dougks, and 11 pene- 
trations at vii(iiial (H'Mnrif* (nio the iitonu. 



PKtiSAHIES 



sa 



with an iiilraiitrririe stem. Wingc<l pessaries of the type of 
Zwank are still greatly employed in Germany, but liiippily have 
not yet been used in France. ITiey are very fref|uently the 
starting-point of ulceration, because tlie |>utients do not take 
tJieni out at night as lliey should and the continual pi-essure 
of tlie wings rapidly ulcerates the mucous inciiihrHnc. 

Unvulcanized rubber pessaries become encrusted with great 
ease; to avoid this take theui out and wash them very frequently. 

As for other pessaries, if the pressure they exercise on the 
vaginal wall is not too cronsideralile and if sufficient cleanliness 
Is observed, complications are rarely observed. 

Indications. — In principle all cases of prolapse should be 
operated upon if there are no conlraitidicHtion.s in the general 
state {(lialjctcs, olwsity, cardiac or pulmonary aflcctions). In 
practice a great number of elderly women, to whom one has 
advised surgical intervention, promptly go to an instrument 
I maker to buy a ])essary with an external sujjporl, wiiich ]>ro- 
nires the retpiired relief. If one talks with a pessary maker 
one can learn of tlie enormous number of such apparatus he 
sells apart from those ordered by medical men, and also of the 
number of women who treat themselves quite independently of 
medical advice. 

If one liiuls a ease of complete prolapse of the uterus due 
to one of these vagino-abdoniinal pessaries, one can give relief 
to the sulTcrcrs by applying a pessary which supports the 
uterus and at the same time corrects the deviation. Ijecause it is 
most frer|ucntly retrode\iated as well as prolapsed. For this 
purpose Schultze's sledgt? [H-ssar)- is the instrument of choice. 

Apart from these troubles caused by a retrodeviation, the 
pessary can also render service if there are not any concomitant 
inflammator}' phenomena, if the ])eriueum is sufficient to insure 
its stability and if the vagina lias not undergone Uie alterations 
of senility, such as rigidity and atrophy, which expose it to 
ulceration aiul the conical form which does not [H-rmit the 
application of (he instrument. 

Willi the exception of these cases a pessanr". well (itled and 
applied, may lead not only to redressing the deviation but also 
lo Uie cure of the condition. This is the opinion of Kustner and 
others %vho have carefully studied the question. Gradually the 





60 



MINOK GVNECOLOOY 



means of Bxation of uterus iK-t-otnc more anil more stren^liened. 
and the uterus can maintain itself in a good position. The suc- 
cesses wliicli our ojierative measures have secured, in that a 
rapid cure is accorded to tlie woman who earns her living, 
should not make us forsake the orthopedic treatment in women 
of comfortable circumstances. 

As a general rule, according to Kustner, Ihc pessary must 
bo worn from several numtlLs to several years until the uterus 
of itself occupies the normal position. If a pregnancy occurs take 
the |K-sKiiry out at thr fifth monlli. 

Hodge's pessaiT or Smith's suffices in a great many cases; 
if a marked rehtxalinn of the posterior fornix is diagnosed, 
Thomas' pessary is preferable. 

In principle. Schultze's pessary is the liesl l)ecause it may be 
mmlified according to circumstances and particularly when the 
cenix is not in the sagittal plane. In such a condition one can 
avoid pulling on the cervix by making the figure of 8 a Hltle more 
oblir|ue: but this advantage is at the same time an inconvenience 
bi'causf it is more difhcult to sha|M^ and can only lie a]i[>lie<] by 
practised hands. 



11. Curetting of the Uterus. 

The curetting of the uterus has for its object the emptying 
of its cavity of pathological [>r<)duets, and of removing in part 
or "in toto" the mucous membrane which lines it. 

History. — It was intr«Mluced into prnctice by Recaniier in 
184G. Its practice was afterward abandoned and later restored 
to a place of honor in the Irealmpnt of malignant tumors by 
Simon in 1874, and in eases of cndomelritis by Ilegar, Kalten- 
liach, and Olshausen in Germany, and by Dolcris in France. 
Tliis n-naissanee of curetting has U'cn folh»ve<l for many years 
by a great abuse in its employ. To-<lay its employ is justly more 
PCStricIni, but nevertheless it.s indications are still very numerous. 

Technic- -Providing llici'c is no call for immediate action it 
is as well to choose one's time. We o|>enite five or six days 
after menslruatioti and pre|Mirc the patient with a bath, an 
evacuation of the intestine, and a preliminary dilatation of the- 
uterus. 



CURETTING OF THE ITTEIIUS 



61 



Tlie last-nnnied measure lias tlie ntlvaiitape of crealmg 
a rcmiiiy eaiial wtiicli ])t'riiiiU uii easy iiiunipulaliuii of the 
curette and a way of escape for intrauterine secretions; it diniJa- 
whp» also the irn-giilHrity of the cervical canal, levels tbc surfaces 
aaci renders the actions of the instruments more efficacious. 

A curetting, if il is performed without the preliminary 
dilatation, is often incomplete and constitutes a poor operation. 
With the exception of the puerperal condition we advise the 
slow to the rapid dilatation. One can use uterine dilators or t>ou- 
gies to complete the dilatation commenced with laminarin tents, 

DilatJition pnKluceil slowly has tlie advantage of making the 
uterine tissue more flexible and of avoiding the tears which 
follow on an attempt to make the uterine canal of the dimen- 
sions we recommend. In addition, note that tlie cavity liilaltHl 
by slow methods contracts on iLself much less rapidly than one 
tlilated just at the moment of the operation wliicli to our mind 
constitutes still anotlier advantage. 

Anesthesia. — \Miile ivcognizing that one may pracli.se curet- 
ting without anesthesia it is nevertheless |>ainful enough to 
justify its use. 

Besides suppressing pain, anesthesia jiermits the drawing 
rlonn of the cervix and a relaxation of the abdominal wall, 
which is of use during the operation. 

In ol>stctrical curetting. |«irticularly when the patient is 
enfeebled by repeated hemorrhages or by a severe infection, 
anestliesia is contra indicated. However, if one has to deal 
with a pusillanimous patient, one may Ik* ))crmittcd to give a 
few inhalations of chliiride of ethyl- 
Operation. — The [latient is placed in the ilorsa-.sacral position 
aith the buttocks resting on the extremity of the table, the legs 
plftccil in su|iporls and the thighs flexc^t and abilitcted. 

We next proceed to the cleansing of the region of o[>eration. 
It hi UM*Icss to shave the mons veneris. It is sufficient to shave 
the labia niajora. The vulva should afterward be well cleansed 
with -snap as also the vagina. Finally these parts are thoroughly 
irrigated. 

The surgeon .sits facing the vulva, having to his right the 
iiistrumenLs and on liis left an assistant readv to take a dilator 
or to manage the cleansing process. 



62 



MINOR GYNECOLOGV 



Having found the cervix, depress the posterior vaginal wall 
with the speculum and take out the laminaria tent. Then seize 
the cervix with tenaculum forceps, grasping the posterior lip 




Flo, 66. — Patient in position for curetting. 



p-iHTiiIIy nl)out 1 or 2 cm. (5"— 5") from its free border, in 
iinliT lo avoid tearing it. We have given up the bullet forceps, 




l''i<i. II". - ■Tcnaculuni forceps for drawinn down the cervix. 

which li-ars the cervix so easily; also those forceps with sliding 
nitcliels hetaii.'ic tliese form in the interior of the cervical 
cavity a tr()ubiosomc projection. Having seized the cervix, draw 




CDRETTING OF THE CTEItUS 



03 



It gentiy and gradually down to tlic vulva. A second forceps is 
placed on the anterior lip and the posterior speculum is taken out. 

The drawing down ))f the oenix has the advantage* of straight- 
ening the uterine canal, of facilitating Uic introduction of instru- 
merits and of suppre-S-sing the oscillatory movements given to the 
organ during curettage manipulations. 

With the hystcrotorae one can find out the direction and depth 
of the uterine cavity. If the dilatation is insufficient it may be 




Flu. UX.— t'l4>rine ourrttr. 



completed with the aid of Ifegar's dilators; tlieii one can proceed 
to the curettage. 

There are a great niimhcr of models of curettes. Specially 
useful are those of moderately sharpened edge. 

It i.s well to have two or three of different calilH'rs. In <»rder 
to enter into the uterine cornua, a little ring curette is very useful. 

To be quite efficacious, curettage should be methodically done. 
One should begin by piLsliing the instrument gently in until it 
comes into contact with the fundus. Then proceed to curette 
both walls of the cavity from above downward. First of all the 
soft tissue is removed, the debris of the iriHamed mucous mem- 



Kb 



Fto. C9.— Riiii? curette. 



brane. One re[)eats the manipulation on the same wall several 
times until one feels the special grating sensation described in 
France under the name of "crl uterin," u scn.sation which is of 
touch rather than of hearing. One should supjjort the wall 
which one curettes with the aid of tJie index-finger of the left 
hand introdu(x*d into the fornix corresponding to the anterior 
or posterior wall of the ut<Tus which one is scraping. 

The curette should bo brought out to the external os with 
each sweep of the curette in order to bring out of the cavity the 
doti and mucous mcndirane debris. 

From time to lirae wa.sh the curette wilh sterilized water 



04 



UINOR GYNECOLOGY 



or an antiseptic solution In order to empty it of the scrapinjj 
wliicli fills its favily. 

At the level of the cer\'ix where the epithelial crypts are dee|ter 
and k'sions more pronounced liian elsewhere the curettage 
should he more particularly enerj^etic. One should ho particular 
to scnijie also the angles of the uterine cavity with care, and fofj 
this purpose the ring pessary is hest. 

Generally the uterus contracts during the curettage; excep-l 
tionnlly its cavity increases in siite and the curette misses the 
resistance it felt a moment hefore and one is led to think of I 
uterine |>er ft nation. One must then iintntiliatety withdraw the 
instrument and press Ihrnugli the ahdominal wall the uterine 
glohe which can easily lie seen; as a result a certain quantity of] 
htoud comes out an<l the organ contracts again and one is cnahled 
lo continue the curettage. 

We arc accustomed lo finish with a curette attached bv a 



Fio. 70. — Inignting eurctt*. 



tuhe to nn irrigating can. which comhination has Ihc advantage' 
of emptying the cavity of <h'hris ami at the same time completesi 
the cleansing of the angles of the uterus. 

After douching in this manner, cauterize the uterine cavity' 
with a mixture of creosote and glycerine (creostite 1 part. 
j^ycerine 2 to 5 parts) or with a solution of chloride of zinc _ 
(I to 10). I 

Dolerisi has introduced a s[iecial hrush for this stage of the 
operation. We use a simph- vaginal dn-ssing forceps armed 
with some hvdrophile wool. Having impregnated the wool 
with some caustic Huid. we successively rub the walls of th6' 
uterus, exec-uting niovomeiiLs from l>elow upwnrd ami of rotJilion. 
The |>ortion of wool we usv sliouhl extend far enough d<>wn the 
forceps in order not lo entirely enter the uterine cavity, lliei 



cl'nETTixt; or the ltekl'8 



6S 



neglect of Ihis precaution often leading to tlie catching of the 
vtHtl just iibove the cervix when the forceps are withdrawn. 
■ During the cauterization be careful U* [ilaee on the posterior 
fornix a tampon of wool in order to catch the excess of the caustic 

IBuid which niav discharge and burn llic vagina. 
Finally, drain the uterine cavity. A gauze drain is generally 
u»c<l. hut v/c prefer a rnhber drain. Once the gan/e is well 
K saturated with the products of the secretions, there is a risk of 
complicalinn.s rrsulting from retention provide*! the gauze lia.s 
not been uccuralely plHee<l in contact with the uterine walls. 
.\Atick of iodoform has also been recommended For introduction 
into the uterus. 

.\s a last precaution we tampon the vagina lightly with 
iodoform gauze. 

After-treatment.' — Exceplinj; the occurrence of complications 



i 
I 



\ 




Fia, 71. — DoUrw' brush. 

such a.** arise of temperature we remove the di'essings on the 
Iliinl day. If there is well Toarked oozing through the vaginal 
tampon, wo change it earlier. We take out the tampon, irrigate 
the vagina freely, and insert, a smaller drnin into the nlerine 
Mtity an<i again lightly pack the vagina willi iodoform gauze. 
The- second dressing is usually done on the sixth day and after 
llat the uterine draimige is dis|>enset] with. About the ninth 
'lay we relinquish the vaginal tamponing and give oncv <lailv a 
'ni' vaginal irrigalinn. Tin- |mtirnl should luive the bowels 
opened on the third day. 

The conlinemenl to IkhI slnndd generally be about ten days; 
pcrhajKi it may l>c necessary to prolong thi.s interval to three 
■etks where there is nn imperfect involution of the uterus, and 
for s|jecial reasons. It is of advantage to restrain from sexual 
OOfoinunication for about six weeks. 

Complications.— Cure I la ge may be the cause of certain 
rotn plications, those produced <luring the <>|>cration and those 
ruulliiig more or le-ss from it. 




66 



MINOR UY.\'FXXIIjO«Y 



le. 

I 



Per f oration. —'Vhv oi>eratur may perforate the uterus. Thu 
accident U most iipl to occur when the ciireUuge is (loiic at 
lime iipproaching confinement. 

There is generally HtlJe lianger If the o]HTalnr stops at »nce' 
and places n drain or an iodororni gauze drain immediately in 
the uterine cavity. 

Coses have occurred of operators making; veritable ruplurejB 
in the uterine wall. In a, casi^ rc[M>rtc(l l>y llotfmann. (he 
epiploccle enjjajied in the wound in the uterus and pi'nctrale<l 
as far a.s the orifice of the trrvix. Ile-sscrt' was obliged to open 
the abdomen and resect a segment of the intestine, which the 
curette had injured. Many a time Ihe su])puration of the pelvic 
cavity has Ih'cu recorded. m 

IIrmnrrlt<i(/<: — It is rare to find that the blc^ing accoiu-" 
|)anyin^ curetting a.ssunie.s proportions which cause inf|uielnde. 
If a serious hemorrhage is produced during the operation, it 
generally results from a too superficial curetting and it cai 
best be dealt with by completing and terTuinating the .scraping"^ 
of the di.seaswl and bleeding nnict>sa. If, however, the hemor- 
rhage [KTsisLs, it might be necessary to do an intrautcrir 
tamponing. 

Secondarv hemorrhages coming on some days after 1 1 
operation are exceptional and result from infection of tl 
uterine cavity. 

Infection. — Complications of infection result from a faulty 
technic. It Indioows the surgeon to avuiii Iheni. ^ 

If one observes after curetting a slight rise of temperature,' 
this may lie due to a defective <lniinage. It is poHsible that 
the gauze plug is acting as a tam[ion and preventing Ihe ulerinefl 
secretions es<'a|)ing. It is therefore in<ticate<l to remove the 
plug and replace with a drain. A fall in temperature to 37" C 
or 98° Kahr, is the result. 

Graver complications of infection may come on as a restill ol 
the o[»erative or postoperative septic involvement of the raw 
surface cn-ated by the scraping away of Ihe mucous membrane. 
This septic eintonielrilis is comlHited with free intrauterine 
douches rejK-ated several times a ilay. If tln-M* septic coinpH- 

* HcViiTl I Willinnit. Arnili-tilal PrrfoMiion of Uw I'lcniii iluririK Cuifllinit. A 
wiUi Ih>h<'I iiiitirv nii'l rv^Tlii>n e4 futir iwX tA ()i# •mnll lnle>(iDi-. t<ln, JovnuiJ 
(VMttr., Iliil*.. lOo&. T I,. |> 2(1; 



\ 




CUKEITINO OF THE L'TERUS 



67 



'cations persist, wc may hovo In perform liyalcrectomy in order 
to avuid u generalized iiirectioii ot-<'urring. 

In other chsch, Gnally, tlie teni])eratiire rise reNtilts rnini an 
involvement of tlie ndneTca. This condition shouJd be treated 
with aixsolute repase, adminiKlnition of opium and ice to the 
iilHlonion. 

SUrilUy, Strirture and Obliteration of the Uterine Carilif. — 
Sterility lias been known to come on after cureltinj;. This 
ILs most often from atresia or even a partial or romplele 
oHitonttion of the uterine cavity. The way this condition is 
brought about can be easily understood. It is known how the 
nnicous membrane rajiidly regenerates, after curetting, by the 
niultiplicalion of the cellular elements which line the recesses 
i)f the crypts of the miu-ous nicinbrane and arc ordinarily s|>iireii 
by the curette. If the curetting has been too violent, these 
cellular regenerative nests may be destroyed. In such a case, 
u fibrous cicatrix is produced or even a complete fusion of the 
walls. leading to .stenosis or obliteration. This may even extend 
lo iht* uterine cavity "in toto." These strictures or obliterations 
lead naturallv to dvsmenorrhea and sterililv. 

We comi>at this cimdition by slow progressive dilatation. If 
Ihe stricture is situated interiorly, near the external os, a plastic 
o|*cration i.s in<licalc<l.' In cu.se of extensive strictures or com- 
fkie obliteration, with the existence uf very [lainful cduipllcating 
liysiHenorrhea, hy.slerectomy is the only chance. There are 
Wtiiplicalions which we have never observed and which could 
oolv ari.se by a brutal cnrelting and consequent injury of the 
ulual uterine muscle. 

Cienendly the mucous membrane regenerates rapidly and 
fpfomis its accuslomeil structure. The primary menstruation 
I* simply retarded aliout a month and pR-gnancy may come 
onniuj cuntinue uurmally. 

Failures. — The failures of curetting result most often from 
" fiiulty tcchnic, faulty a.sepsis. an ill considered indication, an 
cutting cervicitis, a suppurating metritis, an intlanimatjon of 
w adnexa, a [M>str)perative reinfection, insufficient <iressing, or 
> IW) rapid rccom mcncenuMi t of .<iexual communication. 

If the employment of curetting is strictly limited to cases 
' *"t furtlwr OB tlw ■' (ipvmlioiM on tli* (ionise." 



us 



MINOR 0YXE001.00Y 



when* it is ri>al)y iiulicatptl. and we will see later iUs indicatioiu 
failures will l>e seen only in <|uile excfplionai cases. 

Indications. — Curettage may be indicatc<i in: 

(!)■ The i)ucr[)cral slate. 

(i) Outside the puerperal .slate. 

(1) hi the J'ueri>f ml Staff. — 'i"he primary indiealion of curet- 
ting in this state is cvacunfion of retained producin, ])ortion.s ot| 
mcnibrHne. placenta, etc., resting in the uterine cavity. If there 
JHa frie hemorrhage, tlii.s evacuatidti should Ik- done immediately 
after the [Mi.s.sage of the fetus; in the absence of com plica lioiu, 
one should wail Iwenly-four to thirty-six hours to see if the 
evacuation will not occur spontaneously. ^ 

GcntTally S]H'aking. tin- fuifjer i.s preferable to instruments. 
\ curette may scrape the placenta without loosening it and may 
leave it "in toto" iu the uterus. The linger, however, feels what 
it is doing, feels what it has to detach, ainl finds the lineof eleitv- 



J 



1 



1 



i'li.. 12. — Ulunl cutviU' for iiucrpcrnl ciirpilinK- 

age. There i.s no question that when large placental masses 
remain iu the uterus, one should have recourse to digilal curettintf. 

To do this the cervix must not Itc elo-sed and one should be 
able to [mlpatc through the atxlominal wall to get the neces.sary 
eontni-pre.Hsure .so as to carry out a good intrauterine palpation. 

In general, one uses a couibinatiou of fing4-r und curette, 
uitiug large and blunt instrument.-* and manipulating them with 
great lighliu-ss of touch. M 

When the iligitid palpation shows all the placenta is removed, 
18 it iie<T!W«iry to curette the n-sl of the cavity r 'I'liis tjuestiou is 
diiicu.sseil. Sihiic say tliat the curette destroys the mucous 
membrane and even the miLscle. that il ojh-us up vessels already 
throndiosed and ])rc|»ares a way for infei-tiou. and that it su|>- 
prc.t.ses a degeiicrotion useful for the regeneration of the mucous _ 
membrane. % 

It apjH'ars on the contrary thai de«-idual retention favors 
hemorrhage, the .secondary dcvelopinent of nu'lritis and of. 



CURETTING OF TEIK UTERUS 



w 



I 



polyps, and that curetting, after the e\'ac-uation of the large 
()el>n.s with linger, ])rcsents nothing l>iil advantages. 

If one is faee to face with an abortion of six to eight weeks, 
one has recourse soicly to the curette. 

The second indication of curetting during the puerperal slate 
is the defflopmetti of ri>mi>licutiims «/ Hi'imia. We have quutc<l 
the ol)jections to the cui-ctlc. Tlie danger of perforating a 
softened uterine wall, of detjiching a Ihroinhus, or of l)ringing 
on a profuse hemorrhage, the impossibility of removing all the 
septic tissues, the risk of generalizing the infection by causing 
the oi^nisms to penetrate the o]>en vessels and by destroying 
the line of defence against the bacterial infection. 

There is some ti"utli in al! these objections. Certainly, in 
severe infections, the uterine wall is often softene<I. particularly 
at the level of the placental insertion; but. by using a broad blimt 
curette an<l by palpating through tin* ulxloniinal wail the 
external surface of the uterus and at the same time manipulating 
the instrument in its interior, we arc enabled to avoid these 
[lerforations. Hemorrhage has never ap])earcd to us in alarming 
quanti til's and has always ceased on giving an intrauterine 
ilonche of hot xvater. 'ITie only objection remaining is that of 
ii general septic infection. It is cerliiin that a rise of temperature 
frequently occurs on the evotiing of the day when intervention 
was carrieil out in a septic uterus, but this falls in a few hours 
ami the i>atient feels l>etter. The curette, by emptying the 
uterus of a large quantity of microl>es and decaying tissues 
impregnated with septic organisms, gels rid of these organisms 
and more or less removes the "milieu" of culture where they 
Iiest develop. 

We are advocates of curetting, while recognizing that the 
indications have U-en exaggerated. It is certain to have been 
abused in the past. es]>ceially when used after the first elevation 
of leni|>eratnre following an accouchement. For this condition 
it i« quite sufficient to perform a full anti.septic intrauterine 
irrigation to see the fever disappear. If it persists, and above 
all. if it is suspected that portions of membrane, placenta, etc.. 
remain, or there are septic lochia, empty the uterus complelely, 
curetting il. 

After the eighth day. curetting, according to some accoucheurs 




■ L>.'<;v 



^** 



* lu.v 'lurmfiil than useful, but at 

- :-> ^mv beyond the limits of the 

uervfiiduiis can only bring al)out an 

,..>iji> M\d the provoking of salpingitis, 



^. .i> K' IS exaggerated. If salpingitis and 

. ■.111*. Ml lifter a curetting on the seventh day 

K^ •uuiitioMs may have caused the original 

^ ,.. , i m»i itivvrrectly diagnosed at the time of 

..,^ .['(Mretit some days later. It cannot l>e 

x^..,i^- LiK^e iimditions come on secondarily that 

N.-V- .N I'nk'" js a c«.>nsequence of intervention. 

. -v.*, ,;.,<\'iUiiit, liefore concluding the curetting, to find 

.V . .^ •. "u" tVver. It seems certain that after the first 

, y N- t»t,-i >ivnis to Ik" connected with an extrauterine 

■„■ . .vi ^»c 'iiu-it investigate this. But if nothing exists to 

., V .>. .k'^'.i ■.•!» ;tu extrauterine condition and if on the con- 

. . .K' ^^-N^'iKv of a vilerine discharge leads one to think of 

„ ..,M■..l^^K'll of some retained ]»roduct, there should 1m? no 

:^v....'xM V rise of temjjerature during the first day or two 

i-.x>» ;';; xiuHiUt lead us to think of an intranterine trouble and 

...».■•>;; lu'* il'' value then. It i.s necessary to irrigate with 

. ..Av^'iiv M'lution hiter. once the uterus has l>een emptied, and 

...vv- .;i .1 drain to .secure discharge of the uterine .secretions. 

I: ■■> \cr\ evident that when profound toxemia exists and a 

.^iiMlili-.. pblebilis or a peritonitis manifests itself, the question 

.V ■.'i\' uulu-ation i»l' <'urctting does not come forward. 

l>n the contrary, when after an o])eration there has been a 
^■■n|■^•^.n■v amelioration of symptoms and complications reaj)- 
■.sMi. the intlication is for another curetting. 

^■■." . I I'iirl from the Puerperal S/rt/f.— Ajjart from the j)uer]>eral 
>.i,d\'. i-uivtting can be carried out as a means of exploration, as a 
, iii.itivc treatment, and as a (wlliative treatment. 

V- l\v[ilorutori/ ('iiretHn<i.-—Jn certain cases of uterine hem- 
,>iih;ii;>' of an itisuffi<'iently <letermined origin, and particularly 
it .iM inlrauleriue epithelioma is suspected, one should, without 
deUn. i-urettc. If it is a question of simple inflammation, that 

■ >!•.■ (Ill' iliM'ii—ii'ii "( llic Socii'-ti!'- ircil),-i|<'tric]iii', dc nyiiicoldcic ct lie [iMistrip of 
Vi'ii! .tml M:iv. lliii.".. ;iii,l ;il-o I'lisiurauil, T.ii cim-ttiiKi,' :'i lu clinuiuc Buudelocque. Th. 
.'■ -•■■< hHi;. liKMi, Sti. :)s. 



CUHETTlNCi or THE IITEUUS 



-I 



I 

I 

I 



II I)e the best meansof rnringit;if it isa question of ppilliclioiim. 
Ilic <]iu};iiosis limy l>e lua^le early enough to hoi)e for u cure with' 
a radical operation. 

Curetting shouh] alwayn be done mniplrtcly. In the first 
place, t^ecause it will only lead to a cure, if all the diseaseil parts 
of the inueous nien-brane are removed; in the .sec-ond. bwjiu-se 
a cancer at the beginning may be localized to only a small part of 
the eavily, and if the eurclting is not complete, it may pass nnper- 
ccivcd. Ill short, we ri-ject completely anil absolutely all curette 
explorations which are done without preliminary Hilalalion and 
remove a small piece of tin^sue for examination. 

B. Curetting na a Curative Agerit. — ^The triumph of curetting 
as a mejiiu; of cure is ehronic bemorrhagir ciulnmctritis. Curet- 
ting can also render service in hemorrhagic glandular hy(»er- 
trophies oliscrvcrl even in virgins and certain rases <»f slerility; 
combineil with dilatation, it is oftttii eiumgh ol>served to be 
followiil by conception. American gynecologists freely accept 
this as an indication for curetting. The existcneo of inflamma- 
l»rj* conditions of the adnexa eontrnindicate curetting; a slight 
intervention in llie uterine cavity even may lead to the lighting 
npof these troubles and be the origin for the provoking of a pelvic 
peritonitis. 

C. Curetting aft a PnlHative Agent. — Ciirelting lias been 
pnu-lUcd often enough under the heading of palliative treatment 
inonler to combat hemorrhages connected \\ ilh little fibromata. 
ffo do not feel inclined lo advise it in these cases — ^seeing that 
only n temporarr relief is obtaineil tn tliesc cases and the patient 
ii fKpostil sometimes to inflammatory complications following 
Uie trealmenl, such as the deformalion of uterine cavity. Iwidly 
•InlneH. and often infecte<l, which may perliaps lead lo these 
Wniplications. 

On the contrary', in cancer, may be of the cer\"ix or of the 
wxly, curetting is most useful when abundant hemorrhages exist, 
■I'laUo fetid discharges. By suppressing for a time the cancer- 
ous outgrowths, the patients are greatly i-elieved. 

The first sweep of the curette sometimes brings on an abun- 
(Ittnt hemorrhage and as no means exist to stop it we must ra]>idly 
0»Hnue the ojieration. If all the friable cancerous masses are 
ftoioved, hemorrhage stops of itself. If some debris from the cei^ 




72 



MINOR GYNEOOLOGY 



vtx still remain fixed and fiojU al>out in Ihe cavity, excise tlicm 
witli till; Mcissoni, attach arlcry fonipps and tic, if one can. the 
bleeding vessels. When the curetting is finished aiul Uie cavity 
well cleansecj, pass tlic therm o-cautery over its walls and tampon 
with iodoform gauze which may he removed in three or four flays. 
It is sometimes astonishing to see the way in which the parts 
recover, and wliere at the va^'iiial fundus one lia<I left » cavity. 
quite irregular in outline, a sort of cervix re-forms which would 
givenosuspicionoftlie previous existing conditions. 'I'hc patients 
are greatly relieved, hecome more healthy looking, and increase 
in weiglil antl for llic time helicve thcniselvcs cured. 

Unfortunately, at the end of a variahle period, the old tronhle-i 
once more appear, either the hemorrhagic losses or others. Again 
one may recoinnicnce curetting and if not to |>rol<mg life, make 
it more pleasurable. 

In the course of these curettings one may 0()en the recto- 
uterine sac (pouch of Douglas) as a result of cancerous extension. 
This accident is n(»t .so grave as one would think a priori. It 
suffices to in."ierl an iodoform gauze drain at (he level of the [mt- 
fiinilion to see the healing rapidly [irocecd. 

The opening <tf the bladder itself, much rarer than the other, 
Hosca as a rule spontjineously iti a brief |ieriod. Nevertheless. 
»e advise to abstain from intervention when we (ind by examina- 
tion a propagation of the disease to that organ. This is even 
nuwv to lie olwer^'ed when the rectum is involved. 

In closing, we should like to add that the curetting of cancer 
U Mill indicateil as the first act in the big operation of excision. 
mwX this we will deal with later iu the various procedures of 
^jnUeitH-tomy. 



f 

I 




CHAPTER in. 

PHYSICAL AGENTS IN GYNECOLOGY. 

Summary. — Rlectn>Uternpy (instruments, pIivHiologit-al Imiscs, indica- 
tions), — Kinrsithprapy. — Hydrolhcrapy.^Mincral waters. 



1. Electrotherapy.' 

Electricity has many and varied uses in ^nocologj'. It 
would l»e wrong to imagine that electrotherapy is of as great a 
iiiiigiiitudc as the nie<lical and surgical tlu-rapy. Klcctricity lias 
its place among other agents in Ihe treatment of the diseases of 
women, and its Indications arc supported hy experiments now 
quite old, and hy the more recent developments of electro[)hy- 
siolog;j'. This latter science's development has consi<lcral)ly 
diminished the empiricism in electrolhcrnpy, and among the 
gj-necological indications there are hardly any which cannot he 
supported by rational and precise experiment and ohservation. 

The majority of affections demand, in their eleclrical treat- 
ment, few instruments of a simple nature, which could lie the 
pro]>erty of everj' practitioner. Those are rarer which refjuire 
nn outfit of instruments of a more complicaled nature, and which 
consequently constitute more the arsenal of the specialist. 

Instruments. Physiological Bases.— With a good pile Iwltery 
and a constant current, the gyncculogist is in a [)osititm to do a 
great deal. If he posses-ses in addition a means of procuring 
high frc(|uency currents, and an X-ray ap|mratus, he will he able 
to do everything. These latter lie. Iiowever, more in the province 
of profcs~sional electricians and arc besides very diflicull to 
transport. 

A gooij batter^' for the procluction of a mntinwnm current 
should comprise about thirty elements. The most practical type 
is the hisulphate of mercury pile, the price of which is moderate 
and its longevity remarkable. These instruments are always 

' All tbe cleeUutlM'rap)' text li«i Iwcn dmvrn up by U. ZimiDem, prDfrwiM at pttjrtioa, 
Pmm Cnirwndly, 

73 



74 



PHVSICAI, AGENTS I.N (:VXKC"01.(KiV 



furnisli«l wifli n ^rmliiateil scale, winch cnalilcs iis to use llic 
current at a desiretl strength, also with a meafiurinj» instrument, 
milliaiiipere-rneter, the eleetrotlierapeiitist's scale, as it has been 
called, which enables us to find cmt at any moment the intensity 
of the electrical application we are making. 

Two electrodes, one fixed to the copper pole ( + ) of the bat- 




fto, 7S, — PoftabI* bwltery of liiaiilpliittv of mircury (LHy'v moilul)' 

Icry, tlut other to tlie zinc ( — ) form the contact of the current. 
Two wires place these in com m tin ica lion with the instruments 
which carry llie current to the tissues. These iiistininicnts arc 
called electrodes. 

The eleetrtMles are eitlier metallic or spongy. The latter con- 
sist of a metallic plate covered over with several layers of hvdro- 




I''m. 7*. — ^Spongy elcctrodw. 

phile ^auzc or even ijctter of plaited hydrophile cotton. These 
are plunged into lukewiirm water whii-h is to a certain extent re- 
tainer! in the meshes of the tissue. They are generally applied 
to the abdominal wall. .\s these electrodes have no special action 
at the seal of eoniact, but are only of use to en-ate the electric 



-1 



ELKCTROTHERAl'V 



76 



I 

r 



I 



orcuit on tlio abdomen, they are called iiulifferent electrodes, in 
conlradislint'lion to those others wliicli nre inlnMluced and aiJidiwl 
to a i»oiiit ill the genital canal and are called active elcctrode.s. 

Active electrodes are made of metal or of horn carlKm. 
They arc sha|HMl like .sounds ami are made of platiniun, copiier. 



=»C 



9=m 



Their stem 



I 






Fig. 75. — Active clc*t.rode. 

zinc, nickel, or silver. They are fixed on a conducting handle, 
which the doctor holds, and surrouinled by an isolaling sheath 
which in intrauterine manipulations protects the vaginal WiilLs 
from the effects of the curix'nt. 

The carbon sounds are slm|)ed like a little reed. 
is i^wlatcd. Of the two extrrtiiitics one, M, is 
attached to the conducting wire, the other, (_'. car- 
ries the current into the uterine cavity. 

At other times the carbon sounils are utilized 
not as inlniuteriue electrodes, but as vaginal ones. 
lu such cases they are cnvelofK'd in a triple layer 
of hydrophile cotton, and later are soaked in water, 
in order to transform them into spongy cltM-lrodrs 
and in order not lo injure Uie walls of the vagina 
by cauterizing them. They are intrixlut-od into Ihc 
posterior vaginal fornix. 

The electrode covei"ed with tnoistriiefl" hydro- 
phile cotton is exclusively reserved lo vaginal a[i- 
plication.H. The plane electrodes on the contrary' 
are used for intraoervical or intrauterine applica- 
tions. 

It is generally easy enough lo infri)chice a liys- 
terometer, at least into the cervical canal, without 
iiu]iectJon. The siieciiliim is usually more trou- 
blesome than useful. With the second and index- 
fingers of the left hand, a little gutter is formed 
along which the instrument is made to glide into 
the een'ical canal. In certain cases the conforma- 
tion or Bcxioti <>f the uterus pn-vents its |>enetration 



fiu. 76.— t'oriiim 
clodrodc. 




76 



PHYSICAL AGENTS IS UYNECOI-OGV 



farther, but it is iil limes [wssihie. either hy depressing the fun- ' 
dus of the antcflexL'ii uterus with the rij^lit hand placed on the 
abdomen, or by inclining the cervix posterioriy with the liys- 
lerometer itself, to introduce the instrntnrnt right up tif the 
fundus. 

These manipidations, l>e it understood, are made with patience 
and gentleness and it is useless to add with a perfect aseptic 
technic of hands and instruments. 

The physiological proiH'rties of Uie continuous current are 
chemical and motor. 

(a) The che-miettl itciions may be understood from a study of; 



yf VmuuI •ppDmtioo. The okctitMle \» in the poilcitor foTDlx. 

It is known, however, from the study of lliese 

■ tlwt we nmy c*>iTipare the organism to an electrolyte 

nf chloride of «o<lium; in other words, to a substance 

b* the i-onlinuous current. Physical chemistry 

at » solution of sodium chloride contains fragments 

.v-ttUi>l >*"»■* ""•' literally charged wilh elcclricity. 

div«, -MiUK negative and if the number of + is equal 

n)i — iuUtf. ihey ncutrnli/e each other, and the solu- 

iwMtnl Now . if by passing a current through 



ELECTROTHERAPV 



77 



such a solution one can create n difference of the potential, the 4- 
ions or anions go to llie negative pole anil the — ions or rations to 
the positive pole. On contact of the two poles the elcclric dis- 
charges destroy each other and the molecular fragment de]>rived 
of its electrical charge btH-omc-s a free atom. At tlie positive pole 
in our atnive considered electrolyte, the atom CI. \Yill lie deposited 
and at the negative pole the alum Na. By a secondary reaction 
these atoms will enter into combination with the water of the 
electrolyte with the result that at the positive pole we get a fornia- 




Pia, TA.— Intrauterine npplication. 'ni« righi, hand prussw tlowti the Tundiu of the 

I'un of hydrochloric acid with a liberation of oxygen and at the 

negative pole, soda witli liberation of hy<irogen. These elements, 

"1 proportion to their production, exercise wIihI is known as 

a tertiary action on the tissues, wliicli varies either according to 

iJic |iole (acid cauterisialiou at + poh- and basic cauterization at 

IW — pole) or according to the concentration of the acid or the 

base formed. .\ feeble concentration and a feeble current 

prorluce only niodifving effects: a powerful concentration and 

powerful <'urreul proiiucc caustic etTects. 

The [Mksitive pole is above all employed as an acid caustic in 
order to modify the uterine mucous membrane, but it* eimential 
utility springs from its coagulating pro]>erties attributed to the 



78 



PIIYSICAI. AtiENTS IX OYNKCOI.OOV 



Bcitls foriiifit. Tills is, at leasl. a theory which lias long held 
|iri<l** i>f plurt'. [)ut wliich is opposMl h^v the feeble coagulating 
iHiwiT uf hv^lrochloric acid. 

It wonhl appear Uiat llie nejijitive [jole pro<luccs clinicaHy 
nnaloctius hemoslalic effects and of such a kind thai it has Iw'cn 
thuiighl n('c«\ssarv to furnish another exjjianalion of Uie arrcAt of 
tiliTine licnion'hagcs li_v the continuous current. 

The importjincv of the negative pole springs from the fact 
Hint, placed in contact with sclerosed or eicatricial tissues, it 
chnnges their consistence by a process still unknown. Iml un<lc- 
niahlc and which is currently known uniler the name of sclerotic 
action. We can prove this action in the following manner: Cut 
K hard-boiht! egg in half; staml it on its hase in a glass sur- 
rounded by a thin layer of water. Make contact betwci-n the 
water and one of the poles of the pile with a metallic electrode, 
nnd connect up the pointed end of the egg with a metallic 
rod. which is held vertically and in communication with the 
other [M»le uf the pile. If this rod is attached tu the [>i»silive pole 
and a current of 5 to 10 niilliamperes turned on, no change 
occurs. Now, however, if the rod is attached to the negative 
|K>le. it is observed to sink into the albumen and by its own 
weight transfixes tlic egg. This is an elenienlark- experiment 
whicli shows the sj)ecitie flexibility producing action of the 
cathode. Based on this nclion is the trcalinenl by the elec- 
Irolysis of strictures of canals such as the urethra and esoph- 
agus, etc. 

The action of acids developed at the positive pole is made use 
of in actions on the tissues when ]>latiniim. nickel or earlmn hys- 
teronielers are used. But if metals like copjjer. zinc or silver 
arc U!*e<!. there is a simultaneous attack of the mclal by the 
hydrochloric acid and the fornmtion of a metallic s;dt which is 
in all probability an o.\ychlaridc of the m^lal used. This new 
bo<Iy then behaves as an eh^lrolyte, that Js to say, the ions are 
displncitl. and the (Mwilive ions arc drawn towani the Ciithmle. 
The result of this is thai llie metal — ^a [Mwilive ion--])cnelrates 
mim- ur less dernlv int«) the tissues. This ac-tiou. formerlv 
deseribe<l under the luiun' nf rata fitiore^iiii or intrr«tUial etectrolygh, 
is kni>wn to-<iay as rlrrtrttli/tic iufroiltirlum of mrUillic uniH. 

The silver ion is one of those which \< said lo Ite nmst cflica- 



i 
I 



« 




lil-FXTROTHKRAPY 



I 



CIOU8. Its eniployiiient in fleet rat lie nipy by the gir'necologist 1ms 
preceded by a lengthy period tliP therapeutir agents colloidal, 
protiirgol and c^UargoI, etc. 

The zinc ion was iritrodueed bv I>educ, as possessinfj most 
precious roagulaling prop-rties umi is consetpiently used in 
uterine hemorrhages. 

(b) Motor Actions. — It is known that the .sudden closing or 
breaking of a continued current produces a contraction of striates! 
muscle. This contraction is .sudden and r-api<l as lightning. If 
a continuous current pa.ssing Ihrougli a. muscle is .suddenly 
broken, the striated muscle contracts at the precise moment of 
the break while the passage of the contiimous current has nn 
iiclion upon it. 

It is not llie same with non-striate<l niasele. A break or a 
rapid closing of the continued current is without any influence 
on the element.s unprovided with fil)rillar .substance. The 
ircoplasui only [K-rniit-s i>f being excited by a stiinulu.s extending 
rera longer dunition, thai is to say, by an extenilcd wave. Those 
who pnietiee electro-diagnosis know that while .striated muscle 
normally replies to the short closings and openings of a current. 
whi-n degenerated it demands a protongc<t .stinuilus. The mu.s- 
cular contraction is in llie.se cases a slow and worm-like move- 
ment. Thu.H we see that degenerated striped muscle behaves 
as smooth muscle does normally. 

It is the extende<l wave of the continuous current which is 
suited to the iTitestincs and which is employed in the so-called 
electric douche; this .same is also l)est suited to Ihe stimulus of the 
smooth uterine muscle, when its euntraetile powers arc about to 
be stimulated. 

Ix't us add that Ihe excitability of smooth muscle fiWr pro- 
ceeils more or less for .some time after the n|)j)licution and it is 
cxhibitcti in the intestine by inerea.sed peristalsis and in the uterus 
by an awakening of its muscular funetioti. 

Such are the es,scnlial physiological [)rinci[>les on which are 
baAod the application of the continuous current in gynoc<)logy. 

lllglt frequrnri/ rurrcnis result from the discharge of con- 
dvium. ticnerally their tension is raised by an a|)paratus called a 
rfsonator. at the extremity of which a current or sjmrk is receivwi. 
Appropriate electrodes complete the installation. These high 



80 



PHYSICAL A(iENT8 IX (;Y^■^:(X)L{laV 



frequency currents t-realc ino<lifi<'ations in the iot-jil circulation. 
For this purpose, they are ust-d as anti-congestiou Hgcnls and to 
hasten the repHir of wonnd.s. Note. also, that a remarkable 
analgt'Jiic ])ovver acconi|)nnies tlicsc actions. 

The 8park has l)een re<'oni mended as a cancer cui-e. and the 
^rcat a<lv(Tti»cnienl it received cnalilcs us to omit its description. 
However, we have learned that the electric spark does not destroy 
the neoplasmic <'ell and that all the good results said to come 
from fuljiuration may he attributed partly to the simple removal, 
partly to the cicatrizing or iditic' action, as we have called il, 
of the high fre(]uency current. 

The X-ray.s have also their use in gynecologj*. It is known 
how these invisible rays are produced from elwtrical energi' by its 
|>assage through a rarefied gas. 'I'heir injurious action on the in- 
tegument and the radio-dcrinalitis producefl has formed the basis 
of numerous therapeutir experiments. As the result of much 
patient work contribuled by all the leading radiologists of the 
world, wo learn that X-rays possess a specific action, winch is 
elective on the cellular elements of the blood, the spleen, the 
genital organs and skin. A sufficient charge of X-rays will 
destroy the while corpuscles, the white cells of the spleen and 
medullary cavities and the cellular elements of the testicle. s|H'r- 
matogonia and spermatocytes, the ovules, and epithelial tissues. 
These strictures are broken down and reabsorl)ed. 

The sensibility of epithelial tissue in direct contact with 
X-rays has lc<l to their employ in treatment of neoplasms wherir 
much success has Ijeen obtained. Unforturmtely the very rapid 
alisorption of the rays by (lie su[)erficial strata limits their aclion 
at any depth, and it would sccni to be of little use for deej>ly sealed 
neoplastic growths. 

It has betMi suggested thai X-rays may be used for rendering 
women sterile, but it has been held bv others (hat such a lil>ertv 

* V 

of practice would lie a great .social evil. There is no <Ioubt that 
the danger is n great one. but a knowledge of radiology would be 
retpiin-d ami that could only Ik* accpiired by those who made a 
profound technical study of the subject. The application of 
sufficient exposures to the ovary in order to secure an atrophy of 
the corpora lutea would also demand some sjtecial means lo 

' Front (A^t. eicallix. kixI rXwiir. (o (onn. 



KLECrROTHERAPy 



81 



I 
I 
I 

I 

I 



correcl tlic effefU produced on tlio tissues intervening Iwlwocn 
the skin and the ovaries. 

Indications. — With a knowledge of lliese elements of physics 
and physioli>gy, we wJH l)e able to ^nisp the jirinciples of elec- 
trical treatment. In the first place we will study the ftinclional 
troubles: in the second place, the organic troubles of the genital 
tract. 

Futwiionaf T roubles. ~\n vaginal applications the vimliiiuous 
current has been successfully employed in amenorrhea coniiiined 
with inJanlUiitm and nplama of the genital organs. \ dozen or 
twenty sittings, bi-weekly, lead nt limes to a sufficient niodifica- 
tion in the nutrition of the organs afUicted with aplasia as to 
enable them to recommence their functions. 

The nervous forms of jimenorrhea are treated with aUitic 
electricity. Bouilly. in one <>f his elinics, has especially drawn 
attention to the role that static electricity may play in favoring 
menstruation or to stimulate that function in young lymphatic 
pirls of neuropathic family or those brought up in defective 
hygienic conditions. 

Nervous dysmenorrhea may be successfully treated in the same 
manner, and, alwve all, in obstruction by stenasis or atresia of 
the cervix that the efficHcy of electriziition is i-emarkable. In 
stich a ra.sc the Hexibilily producing action of the pole is the agent 
we use. The electric sclerosis |)roduc(Hi by intraeervlcal applica- 
tions of the negative pole is best done with Ilegar's dilators. 
The gradually increasing flexibility nf the cervical tissue will ren- 
der its dilatation easy, and a rigid cervix sclerosed by prolonged 
inflaniniation, or bound down by cicatrices will bci'ont<- trans- 
formed in some weeks into a flexible and extensible organ. 

It is a rule that, from the first menstruation on, the pains. 
Connected with the stenosis, become more or less greatly reduced. 
'litis lessening liecomes more and more marketl in the successive 
periods. 

By its simplicity, ease and harmlessness this procedure prr- 

U strong advantages over niHiii|>uhitinns aiming at the aulo- 
tic repair of an orifice, as also over the dilatation with Hegar's 
dilators which only act mechanically and do not alter the tissues. 

In closing this chapter on the functional indications of 
dcrtricily. I would like to draw attention to the astounding ra[Hd- 



I 

peril 



«l 



I'HVSICAL AOENTS IX OYNErOl.OOY 



ily with wliicli rndiotlierapy and the liijjli fret|u<.'iicv t-urn'ti 
sinjjly or comliiiu'd, cuiisp \\w (ILsappearance of siu-li )oc-aIize«I 
finiritu.1 as the vulvar variety. 

Organic Lesions. — When Apostoli. in 1884, proposed the 
roiilhiiuuis cunt'iil uf a \ug\i inti'iisity f«r the cure of fihnnna. 
(jyiu-colofjical siirfjery li»d not attained to that perfection that 
aM'pHis and operative technic have since f^iven it. Statistics of 
thni epoch liear witness to the dangers of surgical intervention; 
it is not then .surprisiri}; that such a mode of treattnenl was 
n'ceivc<l with favor, a palliative one it is true, but rclalively 
harnilesiS. 

To-day Apostoli's metliod has fallen into oblivion. Some 
olwervers Iihvc entirely discrcdite<l it as it was thought that its 
inlr<Kliietion might he a rival to surgery. Such a jKiint of view 
\n entirely wrong: really, the electrical treatment of Hhromns is 
only an auxiliary role in .such eases as are iiiuperalile or where an 
o|K'rBlive contraindication exists. The great principle "Even." 
fibroma producing complications, fincc rccognixed, should he 
removed " is to-<!ay the only line of conduct for tlie pructitioner, 
and it is only in ea.ses where, for some particular reason, an opera- 
tion cannot he carried out that we have resource to the [N)lliali%'e 
nieans the continuous current olfers us. 

Klectricid treatmeiil. therefoix*. is used in ino[«?ral)le case-s 
(tiilien-ular, alhimiinuric and cardiac) ; it should also be used in 
rjUH'H where the si/e of the tunutr or widely cxtendiHl adhesions 
render the operative treatment impraclicable. Sometimes the 
proximity of the menopause is sufficient reason for deferring 
surgical intervention, or even the desire of a young woman to 
becnnie a mollier. In .such cases vcc can more or less make an 
attem|>t iil dectri/jttion in order to combat the most alarming 
xymploms in the |>articular case, viz.. hemorrhage. It is not 
often that in coinjilii'atious of tins kind we get much help from 
elect rieilv. 

There are. however, circumslances which contniindicale the 
eniptov of electricity; Ihey are disease<l adnexa aroimd a Hiiro* 
nniliiUH uterus (ovaro-salpingilis. acute or purulent). There U 
nu iieeil to lay strejw on the dangers that electricily may caiLsc in 
Hiich conditions. 

The o|K'mtive prweduiv in eloclrical treatment of fibromata 



EI.ErTBOTIlKRAPV 



83 



I 



I 



13 quite difficult and deniatuls niurh teclinical traininj;. The 
principal part of the operation i.s tlic introduction of Iht* sound 
{which is tudde of plutiiiuru or carbon) as far as possible into tlie 
uterine cavity. The pasKige of the continuous current of a 
stren^h of 50 to loO millinnipercs. according to the amount 
tolerated, and finally the extraction of the hyslerometer. Kach 
sitting should last about S to 10 niinule:^. With two sitlinpi per 
week the electrical treatment of a fibroma demands from two to 
Kve months. 

In cases where the sound cannot l>e introduced, for instance 
in those cases where i1 might W fleemed necessarj' to tost the 
(Mtticnt's susceptibility beforehand, the intrauterine applications 
are replaced by vaginal galvanization. 

It is difficult (I ffriori to understand the action on the fibroma ; 
but we niu.-st not forget that its efficacy is purely symptomatic, 
thai it doOK not modify the volunic of the tumor, as lias been 
claimed, but that it diminishes the congestive condition, and may 
thus reduce tlie edema, lessen the twitcliing pains, and tfie sensa- 
tion of [)earing-down and the vesical compression and at times 
cause complete disappearuTice of the hemorrhage. 

Wliat is the process upon which this hemoslntic action depends? 
Ajiostoli thought it was a specific action of the positive pole, a 
coaifiilating action combined with a caiLstic i»nc, leading to ii 
Biwlianical obliteration by the formation of eschars. However, 
llitj hardly explains how a little instrumenl like the platinum or 
cirbon sound can be capabfe of exerting its inffuence over such 
uiarea as the internal surfatx* of a myomatous uterus. I'n'<leric(|. 
to whom we owe importance in hislolog\- on the alterations en- 
pihft-red f>y electrolysis, declares that the action of the instru- 
iiMUt, as seen umler tlie niicroseo[ie, is confined to hardly 
vifihle points. 

Wc have propo.scd in our thesis' a the<)ry of the action of the 
Ponlinuous current, quite different from all |)revious ones and 
bued on plmiological experimentation. KeifFer's work on 
iilmne physiolog\' has rendered clear that the uterine muscle may 
l)vroiisi«lere<) as an enornunis outgrowlh of the imi.scidnr coat of 
IJm' ulenvovarian vessels. 



'JEinntcni. I'lerinc IIcnH>rrliaKV«. Tliolr F.lcutriii TrFBiini-nInti(l Bxrito-niolor Arlion 
it Uctlrialy. Pariii. IIKII, Baillif re K C'le. 




84 



PHYSICAL AGENTS IN OYNECOLOGY 



It is known tliat tlic iiii'dfJIc layer of Uic iilcriiH' muscle fillers 
contains some vascular lakes limited by an epithelial layer which 
rests directly on the muscle. The role of the muscle fiber at the 
moment of delivery is besides well known; recall for a moment 
the classical picture of "a thousand living liiraturcs" which cut otf 
the heniorrhajre and now there is no doubt that the uterine muscle 
fiber j^radually Wconies the seal of ver}' active peristaltic move- 
ments, us the result of the prolonged [lassago of the continuous 
current. 

The fact is proved by the colic- of which women complain 
after their seance of electrization, by the facility with which one 
cffe<^ts the formation of a pedi<'le in submucous filiromala tn-atcd 
by electrical means and also the ra|jidity of tluMr expulsion. On 
the other hand, two bitches are sidtmitted to uterine curetting, 
and one of them is electrolized \\hile the other is kept as a control; 
if at the end of forty-eight hours hysterectomy is performed in 
both cases, the control case is foun<l to have an abundant hemor- 
rhagic infiltration throughout the mucous and submucous tissues 
while in the curetted and electrolized ease the vessels appear to Ih.- 
empty of blood. 

The result of oliservations seems to be that by its excito-motor 
action the continuous current acts on the muscular fiber of the 
uterus. Without doubt this muscle fiber is frequently inliiliited 
in its function us regulator of menstruation by the presence of 
the obstruction of the fibroma or. in other ca-ses. in virtue of 
Stoke's law, it is reduced to atnnv bv inflammatorv troubles of 
the mucous membrane, which coexist so frequently with fibro- 
mata. 

The treatment of metritis is an important chapter of gyneco- 
logical electro-therapy. 

We will pass over false metritis, congestions occurring at the 
menopause, and metritis of virgins whicli otter to the electrical 
therajM-utist su<-h an extended field of action, but whose number 
forces us to pass over them in silence in this survey. 

We pass now to the true metnlis. 

The continuous current in chronic metritis has given such 
.sufficiently constant and lasting results that lliis methoil of treat- 
ment may be classed among the best of minor gynecology. 

Two methods lie before us, viz., intrauterine eleetroly-sis with 




ELECTROTHERAPY 



85 



n 



f 



I 



Tibii-acid corrosive electrodes, and the electrolytic intrndiict 
cerUiin ion.s, known as tlif old interstitial electrolysis. 

Tlio teehnic is practically analogous to that which we briefly 
descril>ed above in connccli<>n wilh (ibninia. The vaj^inal uppli- 
ratinns. notwithslandiii^. are only indicated in certain cases of 
hemorrhagic metritis. The (■ontraindicati()n.s resnlliuf; from the 
condition of the adnexa are the same as before. Finally, from 
Ihe [joint of view of the intensity of current, generally one cm- 
ploys about 50 to 80 inilHanipei-es. exorcising discretion of course 
aceonling lo the susceptibility of the patient. \ scries of four to 
twenty sittings, act-onling to the condition, geiierully causes a 
ccssalion of the pains, of the heniorrhnges, and of the leucorrhea. 
Apostoli thought that the dcveIo|nnciit of acids in the ncigh- 
liorhood of the [lositive electrode in the uterine cavity produced 
modifications of important structures in the nnictius inenibrane, 
and even led to its replacement by new tissue. Further, the tonic 
action exercisefl by the continuous current on the nuiscular Hber 
ap|(ears to .V[iosti>Ii as particularly apt to bring about contractility 
of the uterine muscle and thus fortunately to influence the circu- 
latiun of thv organ. 

This excito-motor action on the uterine muscle, to which we 
giro R preponderance of action seeing its hein<>.static cffwts on 
GbroDiala has perhaps, equally, from the standpoint of its action 
in metritis, an influence greater tli.in one would at first suspect, 
la I'ndometrilis, the uterine muscle is directly or indirectly aflected 
l>y the inflanmialor^' process. It is highly probable (he return- 
ing activity of the uterine muscle brings ab(mt important circula- 
•orj- changes in the organ, conse<(uently improving its nutrition 
nil) favoring the carrying of material necessarj' for the defence 
ami repair of the anatomical elements of the diseased mucous 
nwmljra rie. 

As it is <liflicult to admit that the entirety of the uterine cavity 
ran be influenced by the pr<Mlnct-s of electrolysis, still, renierabei^ 
■o^ Ilia I intervals elapse between the sittings, it is probable that 
during these periods some portions of the diseased endometrinni 
firwpagate their iiiseaseti stale to neighboring areas which have 
lince U-ctmie healthy: and this explains why metritis affecting 
tlie iKwiy is so difficult and so long to cure. 

The conditions are not the same in cen-ic«l endometritis. 



86 



PHYSICAL AOBKIS IN GVNECULOGY 



Hoi'p the soiiiKi is t'liihrncecl by Hie neck, and in a few siltinjfs 
the effect ol' tlie poles, aided l»y iliflu-sion, is evidence*! on prac- 
ticjilly the whoU' of tlie inU'rnal cervical surface. As is well 
known, an old metritis tends to become limited to the cervix. 
ami as tin- majority of such cases come to the elcclro-therapfiitisl. 
we can understand the action of electricity in the cases cured by 
these means. 

The electrolytic introduction of "ions" into the substance of 
the uterine mucous membrane nieritj* lieinj; taken into considera- 
tion because, with tJic exception of electrolysis, there <ire im 
therapeuti<' means to bring about the c-ertain penetration of such 
an active substance Im-Iow the e|>ithelial surface. 

•■ The interstitial electrolysis of silver ha.? been advocated by 
Ijpduc, Hoisseaii and Ilocher, The zinc ion ha.s liecn (piite 
recently advocated by Leduc as both an antiseptic and hemo- 
static agent. AtlempLs have aI,so been made with cop[K*r elcc- 
trwles ((Jiautier), iron (Re^nier). and aluminium (Debedat). but 
furtlier experience has not jusliHed their use. The strength of 
current used with these electrodes is frenenilly ipiite moderate. 
It is better not to use more than 51) milliainperes. Each sitting 
shtnild Uisl from 6 to 10 minutes. 

From the foregoing it will be seen thnf the electrolytic proce- 
dures we use in the treatment of metritis arc four in innnbcr; 
simple intrauterine electrolysis where the positive or negative pole 
is actually employed acconiinfj to tlie eH'cct desired, and the 
electrolytic introduction of either the silver or zinc ion. Let us 
now consider in which circumstances wc would eni|)loy citlier the 
one or the other, 

It is a rule to u-se [xwitive electrolysis when the metritis is 
com|iIicated with menorrhagia or metrorrhagia. In such condi- 
tions we are piobabjy <le!iliiig with a corporal metritis. In addi- 
tion, with the purpose of obtaining the caustic action on the 
greatest possible surface of the uterine mucous membrane, it will 
be fovind m()st useful to use carbon clcclroflcs, choosing the 
largest si/,e one ckii conveniently introduce. 

'I'lie use of carbon is particularly to be rtH-onimended in 
oh) metritis and fungoid uielritis. where the Iiemorrliagic losses 
are combined with vegetations on the surface of mucous 



US mem- ■ 



ELliCTUOTiriCKAPV 



87 



brane. Where tlie positive olcctroiysis fiiils, tlie indicvition is to 
lr>' the 7.inr ioii. 

When tlie iiielrilis is aceoni[>.-inie(I hy monorrhagia only, a 

' conititton of alutiy of the uterine muscle Ls ^■nerally routxl too 

and if the tonicity of the muwle is restored, the hemorrhage 

ceases. A few vaginal a]>]>Iieat)ons. utih*zing Ilie exeito-motor 

power of the eurrent only, will l)e roiiiul sufficient, 

I In metritis where the main feature is leueorrhea, we shnuhl 

fcue eleetmlysiis with silver or the negative pole. The former 

seems to exercise *piite a special action in metritis of gnnococ<'al 

orfgin, either at the beginning or in the chronic stale. One can 

almost always obtain very rapid results in these cases. Similar 

resuibi are ol)laim'<l after the u-se of the salt-s of the same metal in 

other manifestations of gonococcal origin, such as conjun<'tivitis, 

cystitis, etc. Silver electrolysis ceases, however, lo be efKeacious 

when the gonococcal metritis l>ecornes very chronic. 

In the majority of clirnnic metrites limited to the <'ervix, in 
Koinen who have luul whites for a number of years, and particu- 
larly in those cases of irritative liypersr<Tetion of the <'ervix. 
following infection, negative electrolysis is the procedure of choice. 
Tbc results obtained under these conditions are. without doubt, 
ilucfor the most part, to the electrolytic caustic action, penetrat- 
inplhe cen'ical mucous membrane deeply. These are therefore, 
oil'rief, the indications for electrical trcatineiil in cases ijf chronic 
tnetrilis. 

It U easy to understand by reason of the physiological elfeets 
of the current that iiterine subui volution may be coiisi<lcre<l a 
*Mp for electricity. The specific action of the continuous 
nirrent on the smooth uterine rauscle fiber is sufficient to render 
thn treatment a.s the best in conditions of involution following 
"II nil accouchement or on an abortion nnc(Hii|)licat(sJ by sepsis. 
Quite recently a case of partial subinvolution came under 
">tT notice which, from tlie standpoint of our statement above, 
*(*in8 ver)' instructive. The case was a girl who after a pro- 
Curcil alwirtion began to suH'er from extremely abumlant hemor- 
rfuiKP. The tcmj>crature was normal, but the patient becjinic 
diily Weaker. Her mcilical iitleTidaiit. an eminent gynecologist, 
baving triwl douches, decided to curette her. 

This diti not give the desired result. The tuni|K>ning wan 




88 



I'lIYSHAL AtiKNTS IS GYNECOLOCY 



continued, as also the astringent applications and erf^lii 
temaily. Thf licniorilmge cunliiiiicd unij 1 was sent for. Her 
uterus on jwlpalion gave me an impression of peculiar n-lux»lion 
and softness, and laterally, in tlio region of the right cornu. uiyM 
linger outlined a very dcjjressible sort of anipullary dilatiition. 
After the second application of intrauterine electrolysis the flux 
diminished by at least one-half and palpation enable<l me still to 
recognize the subinvoitited portion, but very markedly dimin- 
ished in size. 

After the sixth application, about ten days aftertliceleclrieal 
Ircatnienl. the hemorrhages had completely ceased and the ulerui_ 
had reaxsumet] its normal shiijie. ■ 

I have reported thisv-ase, but all eases of subinvolution treated 
by elcclricity react in a similar manner. 

All that now I'emains is to consider the indications of cicctricitv 
in llie treatment of neopUtums of tlie genitourinary- tracts. Unfor- 
tunately, the services it can render in this field are palliative only 
and the hopes thai I wo new methods, radiotherapy and fulguralion,^ 
have engendered in llie last few years, have in a great measure" 
fleclintil. Without doubt, it is possible, with special localizing 
lo iiirttnimenls mucIi as speculums to irradiate a cervical neo- 
plasm through the vagina and we are also enabled with verj" 
penetrating rays "ud by the procedure known as "feu croise" 
lo in-adiate a nt^'rine neoplasm. This metliod, however, which 
might be efliciu'ious if applied early, when the neoplasm iaJ 
limited, loHCH all its curative value if an early diagnosis is not 
made, The same may be said of fulguration, that is, a surgical 
curetting fi>llowcd by a ]>rolonged application of the electric 
Hpnrk lo the resulting wound. There is no ease of cure of a uter-^ 
Hie neoplasm by the electric spark. Its only benefit lies in the 
pnssibitily of le.'isening for a lime the pain and fetid ilischarges 
and of rescuing the jMxir sufferer leinporurily from being an ob- 
ject nf n>pulslon lo her entourage. In ctmtradistinction. the vul- 
var i'pitlieli<una. when limitetl and su[ierficial, is a splendid case 
for radiotherapy and fulguration. 

•i, Kinetotherapy. 

Kinetotherapy, or the thera|>y of movements, has In-cn applie^l 
M» tn-almeni in gynci-ological affections by Thure HrandU, 




KINETOTHEltAPY 



80 



} 



} 



PopiilarizeH in Germany by Schulize and his pupils. Slapfcr' 
iius Ikvii its main advocate in France, from wliose works we 
will borrow' llie main portion of timl wliicli now follows. 

In g\'neco]ogy. more than for any other elass of eoniplainl, 
the fundHmenlal prwept of kitu-lotherapy is to observe grtrat 
gentleness in the ditierent manipulations which constitute this 
method of treatment. 

'I'he patient sliouhl suffer only in exceptional circumstances 
during the sitting; she ought never to suffer afterwanl but should, 
on the contran,', feel irnnuiliately a sense of well-being. 

GynecoI(^ical kinetotherapy should comprise two kinds of 
manipulation: 

1. Movements of massage in the true sense. 
?. The exe<'ution of ]»:irti<'uiar iiu»venu'nts. 
Massage. — The principal manipnlalions of massage arc the 
following, according to Stapfer: 

1. jOirvnlar Friction, — The left index-finger having been intro- 
duced into the vagina^ in order tosiip|)<irl Ihe organs and to guide 
llw niovenu'nts of the external han<l, with the right hand circu- 
latory friction lightly pressing on the viscera which are made to 
roll under the Bngers. 

i. I i7>rfl/ion.--This consists in a rapid vibraton' movemenl 
(ir«cluce<l by the (lalin of (he left hand placed flat on the lower 
(uirt of the abdomen. 

3. 1'reii.ture. — Circulatory friction is accompanied by a certain 
dejjTce of pressure. The corrective pressure is made by intro- 
ducing four fingers of the right hand between the pubis and the 
■Rtcrior surface of the uterus, so as to exercise pressure at the 
fundus of the anterior forniv. 

' 4. Elevation. — Thi.s consistji in ]ilunging both hands open into 
llir utero-vesicat pouch through the abdominal wall and to 
dqires-s the [teritoneHl eu!-ile-sae htkI the anterior fornix of the 
TJigina in such a way as first, to cause the recession an<l then the 
remounling of the cervix into the sacral concavity; secotuK to 



'S««pl»T iH.), TrpntUi- of Kini-l<jt1u-ra]>y, I'line. ISUT, aiul Uyiioixilutficat Kiiielu- 
napy, PMii>, ltflll>. C'lnxiill sUo, Jt-citiU'r luid Huuri-urt. (iyui-oologlcnt (Jvmiiiutiai 
•»d HftDuU TTfilniMil i>( I'ttriiip Mnitwlin anil cif Ibi? .\dm'\n. fari*. ISfll. 



' Kljtpfcr, in ■vccoiduiiri:' niUi Rmndt. inMhU that in onlir in employ lli« inilirx-finfn.'r 
.J« 11* full u^ulnciw, it i. iiTitK'iWMiirr to iW\ ilio oiln-r tliri'c IJnj(cfn into llic palm, 
linuiii ilirm exl^ii'inl nlii-lirly flexed At thi- rin.'taciirpoijhnU!iK«il joint, whicli |H>niiil« 
uiitcx to |[u ia ai for oa tlio di|pto>palnuir fold whioli ivxlii u^iiinNt the (wriiiiMiiu. 
(HliFrwlM? the Mune u (or Vfi|[iii«l (SAcninslioii. 




I'HVSICAt. AGENTS IN GY-NKCOLtKIY 

aiilcviTl lilt- t'lindiis; fhird. to lijrhtly raise the whole organ by 
a gentle vihratorv nuivciiicnt. 

5. Strohimf. ^This is )jerfornu'il jmt rectum; on Uie pelvie 
walls, the ])eriin.'iim and recto-uterine folds, and the pouch of 
Douglas, it is done witli [\u- [nil|» of the index-finj,'»T which 
sln)kes ilie tissues uiMumt more force than would be expended 
in xvriting on a window coated with mist. 

6. Mataration or Kneadiruj. — This is an external manipula- 
tion [jerformed with both hands, uhicli are made to g:rasp the 




Fw, 79.— The patient ii iiciiUf) 
and inrliticil forwani. The ami* 
Arc oxl«ii<Ii.-d ill Oil' line? of indiiiu- 
tion of lhi> trunk. Tim HWiwa nrc 
ciininil liaokivfir'l arnl tuiiwaril it? 
far u» |Kii>HLl>lif, wbilc ihi- iiiusiicur 
gently i-Dilcjivor* tji niiprii'i' lho»o 
tnovr^lnontiri and then lirlnjin ihir 
urniH wit.liuiLl rMintnTic'c frciiii iIil- 
(lulicut's |iurt back tii tbc iioaitiDD 
of <fXlnuiJan 




I'to. SO— Thp patient IiMia ilu^ vxt«n<le(l 
[HiiUioa willi (he p4^lvis Bljirhtly raised ant! 
thd leg* nnd hip* flpicd. She wpAratcs the 
lliiKh* white the nin>M>i,ir. with liauds ciD iJte 
rxternul <iir(iiw i>! tlit- kiii'L-^yrc^ijIsIhiii move- 
ment. Then the miu-seiir Kcnlly hrinex the 
ktieenio mwnnl Ihe niidille hne »ii<l the pii- 
tient t'ii<l<.-at'(ir« to oppuw liim. 



snlicntancous adipase tissue and convert it into folds, which are 
then kneadeti iK-twcen the thumlis and the four other fingers, 
while llie skht is stl-etclied. 

Movements. — .Movements are of three kinds: 1. movements 
which lessen pelvic congestion: i. movements which increase 
pelvic cong(;slion; ;t. respiratory movements. 

I. MoivmeiiU Lessening Congestion. -These are the move- 
ments of flexion and extension of the arms and their aetictn on 



4 



J 



KINETOTHER.«*Y 



01 



M? trunk and also mnvernctits of iilxhiction of llie lliijjhs. 
.These are o|i[k>s<'(| liy tiit' doctor (Figs. 79 and Hit). 

i. Movements Increimnij Congestion.— These arc [lassive 
niovrmi'nLs of femoral circnniductioii and extension and flexion 





Fio. 81 —The pitli«nlh in the hiitf xiTtinK Fio. 82, — Flexion iin<] 

pomtioD. Thu miuMurflpxcH the k-K i>»>l ihe *xt4'nsiun of tlie knt>i> •.•a 

thichMod th«n oiroumdunta (roiii wUJiiimut- wwh foot nllprimtely. Tho 

■srd at tlii^ tiin-jojnl- TUr piiticnl rr'mittn« Mm* ar<- miKcil iiliovc tho 

ptMlve, lb(^ ntliur leg liciiighoUl l>j' uii aMi»> ho»<l, uiiil llit- other (out 

laot. pUevit iiuHti^riurly acIb ■« 

iiKU|)p<>rl. 

oi one of llie K-gs which su|)])orl.s the weight of the body. The 
former give rise to a leni[>orary obstacle to the [ieri|)lKTaI eircn- 
Ution and tlie hitter U'ad to a tension of the abdominal wall 
*hich in turn eoniiHcsses the viscera (Figs. 81 and Hi). 

3. HexpiraUiry Mnvi-nicut.-*.—'\'he do<-tor, standing lieldnd the 
[■itic-nt, raixes the shotdders and arms whih- the ]>atient inspire-s 
J«|>It. Then he allows Uie shoidders to descend during expi- 
Wi'in (Fig- H3). These respiratory ninvcmeiits are in)]iort.')nt 
"1 Uiiil they stiniidate combustion, increase the respiratory field, 
uid by the action of tlie iliaphnigm, cause the elasticity of the 
*U!i|)pn!*ory appiiratus to come into play and thai of the ahdnniinal 
[•dvii; vi*sscU. 

In practice, at the same sitting, are comhincjl massage and 
movements. 

The (Kitienl without disrobing loosens the strings of her 
*liirl and nnbntlons her corsets in such o way as to leave nothing 



02 



I'HYSICAL ACEXTS IN (;VNi;a)LUGV 



to inlerfere with respiration, wliicli slionld always he reguUii 
and fuil i]nriii}( tin* (^yniiuistic niovcriieiils aiui the inassa^. 

If we take as the most common type a case of old exudatt 
the sitting should commence wi(h movemeriLs to lessen con^'stion.l 
Then if the patient is extended, on a lon<; couch, with the thighs 
flexed on the pelvU and tlie legs on the thighs, the masseur 
should commence uith semicircular Trietion and 
vjliratory movements round about the iiterns 
and adnexa, being careful not to squeeze the 
organs. _ 

Tliis massuge, wliieh ought not to la.st morefl 
than five minutes, is followed by movements 
lessening congestion. The sitting is terminaletl 
by passive respirators exercises, followed I>y a 
rapidly executed vibration with the palm of ihei 
hand j)assed along the whole length of the verle-J 
bral colinini. 

These exercises, etc., are continued daily cvei 
(luring nicnstrualion. 

The action of these different inanipulutionaj 
is two-fold. Jjoeally. they increase the elasticity] 
of the agents which fix the uterus and they 
libenite the organs by i-elaxing their attachments, i 
They lea<l to a realtsorption of plastic jirtMluct^j 
and stimulate the nutrition of the viscern. 
improve the general state by .slimnlating tlie 
circulation and diminishing constipation. Some authors find 
that lliey augment the muscular lone of the cardiac muscle in 
that lliey provoke can I io- vascular reflexes, ■ 

Iniliratioiia ami Ctmtrtiitulirntinii^.~The indications of kinelo- 
thera|iy seem limited. They would swm to us to lie reserve*! tt> 
cases of women sulfering from long-standing remnants of peri- 
Uterine inflammation, which has remained long rjuiescenl and 
above all associated with a certain amount of visceral )>tusU 
(slight uterine prolapse, enteroplosis or movable kidney). In 
tlicse cases, the slight degree of gravity of the troubles, their 
multiplicity, iitid the atuny of (he ti.ssues contnt indicate surgical 
intervention. Furllicr. such caKe.*i are common in women of a 
neuFo{Milhic temperament where operative l>enefit is more or| 



Pro, gS.— The 
ma«iieur nuaing thi- 
«lK-rt \iy dnwinit 
the »houl<l«ni up- 
wnrd luid bock ward 
whik thep*ti*iitin- 
ajiirva ileviilr- 

Thcv also 




HYDROTHERAPY 

Icsw illiiMin' iiiul when' tlioy have imicli to unin Ihrougli the 
kinetotlientpeutic uiea^ures to which one might be tempted to 
u(hl liydrothenipy. 

Again, in certain women siitl'ering from ahilominul trouble, 
with ciinslipulioii Hn<l insnflicient inl(>}itinHl rirculHlion, mussage, 
combined with g^-niiiaslic cxcrfisej*. is useful, as tlie abdominal 
muscles are brought into play. 

Maiwage is coritratndieatcd in inflainmutory le-sions, not 
entirely quiescent in which manipulations might lead to their 
rejuv4'nesc('iiee. In oases of recent hemorrhages or of [lurulcnt 
periuterine collections, dittastrous consequences may be induced 
atul in such cases it is rigidly (■ontniindicate<l. 

Sismotberapy.' — Sismothcrapy. which ronsi^tn iii giving rapid and 
HguJAT ribrations of ^niall amplitude during a liricf ppHod, has bcM^n studied 
tiT Jayte- 

Wilh the aid of an pkelric motor and a flexible connective rod he im- 
pirU to m little ii|>|iarntus nf vurii-i] Khupr-i. cmIIwI a "conniieur." a 
nbrstorj- movement. 

It would appear to be a mean* of conibatiiig ^iiiitniinte-ilinal atony and 
juutieulariy eases of nervous wociicn or neiiroarthritics of minor degree, or 
linillr pain when' our unual therapeutic mean; are unsuccessful. 

3. Hydrotherapy. 

We have already had occasion to study vaginal injcctirms. 
fipnerally speaking, hot water is most used, but hike-warm f«)r 
prolonged irrigation and under low pressure may be used for 
lis sedative etfwt. 

Rcclus has become the apostle of hot rectal irriffalion in order 
loconilmt the congestion of the pelvic organs. 

Douches, general or local, render useful scr%-icc as also do Itat 
loiit abdomitiiil comjiresxcs. Cold water compresses are also 
•Bffiil, If a sedative efVtH-l is ilcsired, we use chlorinated 
magnesium waters (Salies, Biarritz); if a stimulating effect, 
*Bh'rs from Halins-thi-Jura or Krcuznach. In very acute 
plilejriuasia, the conliinioiis a]>plicatiou of an ire-bag to the 
afnloinen Is of signal service. 

'Javle and !>»' Ijicroix lif Ij»vollptte. Mrrlianlrnl ^Imnotlierapy In (iynpcolony. 
arnii Jr (t^Hir^«^w, Pariii. 1890. p. 845. Uuucurl, Tn^utmctil uf t'lvnni' .MTfouonh uii<l 
'■'til' Adnexa bv Ueohanio^ luul Kamd Vibratioan. Ann. dc Gwnir., Pa.ni'. ISO>^, T. I^ 



94 



PHVSlfAI. ACKNTS IN (iVXE<'<H.O*JV 



It seems unnefessary 1o dwell more on these |K)ints, whicli are 
not [Nirtit-'tiliirly in our ^yiuH-ologicJil (Joinain. 

Let us add that baths combined with hot vaf(inal irri^ttions. 
general douehe.s, either hot or Scoteh, ami linnlly hieal imtI- 
^astrie douches render f>;reat service in helpinj; n>absorptioii of 
old exudiite.s and in diniiriishiiig those painful eoniplieations of 
which u certain number of women comptnin, and which we^ 
will now describe. Such cases are found to be suH'ering from 
dysmenorrhea with abundant inenstniat flow, whiter, globular 
uterus, sclero-eystic ovaries and painful chronic metritis, a series 
of complaints which Richelol. for want of a better term, has 
described under the name neuro-arfhritic uterine sclerosis, a 
nonienclalnre inidoiiltte<lly erroneous, but enabling us to group 
practically under one heading those particular cbm'S for whom 
operative treatment is generally advised and for whom it presents 
practiailly no utility.' 

4. Hydromineral Treatment. 

This aspect of gynecological treatment is too much jterhaps 
negh-eled by a certain nunil>er of gj'necologists, who imly we 
treatment from the openitive point of view. However. Jiydro* 
mineral treatment is an important adjuvant to onlinar}' thera- 
peutic mea-suri's. 

While actually this form of treatment does not yet rest on a 
scientific base, the information a(-(piire<l by empiric measures 
permits us to afford very useful indications for its use to {Hilients. 



The Principal Waters Used in Gynecology. 

A. Robin an<l Dalche^ have shown the action of ditferenl 
groups of mineral waters t(» which the g^vnecologist has resource. 
>Ve will borrow from their work the major part of the following 
text 

Chlorinated Smla Waterit. These waters are <livide<l into 
those of feeble action (Honrlxm-Laney, BoorlMin-l'.Vrehandiault. 
Saint-Xectnire. la Motte-les-It;iiiis, Uourbonne. rianlenay, etc.. in , 

■ Ridi^lot (t^ O.). Oq llio Trtii1iiii-i>< <>1 IVIvio ARurllonii. Im Ggmmlnfu. pMla,! 
Uav. IWMI. p. 193. J 

' AlUn lUUn an>l Paul Dolcl)^, MrUicnl Trcatiiu'nt of Dim««m of Wumm. Puia,} 
IKO. 



tlYDKUMI.NElUL TKEATMEST 



95 



Fraii(*e: Bailcit-Bjiik'n, Wieslwdcn. Ki.ssiiinoii. alirtHid) ; moderate 
action (Hidaruc, Saliesen Ilaule-daronne. Snlins-<lu-Jiini,elc., in 
Krance : Krcii7.iiat'li, I loiiilioiirg, Naulicirn. Rex, etc.. aliroad) ; and 
stronj( action (SaHeii-*ie-Beani, Briscous-Hiarrilz. La Moiiiliere. 
etc.. in I'ninre; Uheinfrldrn aliroMcl). 

Tlii-y pHHluce in Ihe pelvic orjjans uii inflHUiniatory action 
characlerizecl by a reawakening of pain, an increase in the secre- 
tions, and .stimulate the vitality of the organs. By stimtihiting 
llic circulation these waters lead to a rea l>sorj>tion of old exudates. 
By adding Ihc nuither waters to liuth.s fc4-l)ly saline, the local 
and general reactions are reduced in order to bring about com- 
paratively the properties tending towanl resolution of the .saline 
bath on the local state.' 

Sulpktirouti ll'atern. — These waters are generally noted for 
iHcir excitiHuiotor and hemostatic actions on the uterus. 
Certain differences exist according to the different origins of 
the water. Wliilc certain ones are purely cxeito-motor (C'au- 
lerHs, Lucbon, etc.). others have a sedative action on the 
Hoi'ous system (Saint-Sauveur, Saint Ilonore). 

tt'ntera Feebly Mineral. — These waters generally possess 
»«Utive pro|>erties; Neris w<mld appear to suit the nervou.s 
utprine |>atient who must subnut to a treatment of prolonged 
'wlhiag; Luxeuil. those who suffer from old standing remnants 
"f uterine and peri-uterine inflammations, as also ftiose who 
<xim[Jain of a multiple symptomatic eomplexus. con.sisting of 
»we»ive irritability of the nervous system, whites, anemia and 
tOMlipalion, The treatment here consists in more or less pro- 
longed iMilbs. eomliine<l with hot vaginal irrigations, ascending 
wuches. and lumbar and hyjmgastric douches. 

Miul Itaihu. — .Mud ballis assist Ihe subinvolution of the uterus 
>iil are found at I)ax. Saint Aniand. Franzensbad, Marienbnd, 
UatlAglia, etc. 

Other waters, while seemingly having no dire<-t action on the 
ulenis. may be useful in modifying the general condition or 

'TV rnollirf w»lpr i« the vHiiMri'.li, «vtii|>v lji|iiiil whidi ri-miuiiB u(l*r \Uv rvupora- 
■MB of fhloriiuU-i) wiiien, from nliidi lias Wi'n cximcti'd i.)ii< nnliiiArv comni'-rrial 
•••fch: U IK. in •hitrl, iutcnirlv ■■oiicriitritlrd clitdriniilcil v/aU'T ill whi'Ji llie r»l»livi- 
l*ipMU(in of etilorifk i>( .lofiiiim iu very iiimini*lierl, Tlie !«.i(liili\-p jiirliim of thU molhcr- 
**Mr li kbov* mil ollirn imiM vviiIcriT iii lhi> \viitc'miiiill^n!icii-[lt>-tli'*iirniiii(! of Briiinjiiii. 
*^U«, which MP wry rich in diloricli> nf maRiii'iium. wliilc Ihi- uiiitTx '.if Niiuiirini nnil 
w ytn i c h mtt noldl more for Ihcir Hiloriilo of ■'iilciiimok-iui.-ntsktid tlioacoi KheinfclilfTi 
•tufaaMtsin hanfly any cliloride of midiuui. 




90 



I'HVSICAI, AGENTS IN GYNECOIX)0Y 



<t'rtain nciphborinfi Ipsions which prevent the cure of the genital 
IrouMe. The sotla bieurhoriatc waters (V'idiy, \'«ls, etc.) arc 
tisefiil ill women with herpetic or gastrointestinal troubles, 
biearbonales niixc<l with clilnriiialcd Iiicarbonates (Koyal, Kias, 
St. Nei'laire) in uucniic cases and in arthritic cases, the waters 
or the tyi>e of Chatel-Guyon for ronslipalecl cases with intcstiniil 
plethora, the iron waters (Porfres. Bussang. S{>a, etc.) in chlorotic 
CHSe5, unless we are dealing with a nervous and eretheticat uterus, 
and arsenical waters (I<ii Bourboule) in lymphatic cinn-a. Baths 
of carbonic acid (Royat and St. Nectaire) ai-c certainly congestive 
and may render useful service in amenorrhea. 

Thertpeutic Indication of Mineral Waters. 

Ajnenurrliea. when a.ssociatc<l with chlorosis, is an imiication 
for ferrilginous waters; if the temperament is the lymphatic tyfR*, 
saline waters are useful; if Icucorrlica also coexists, sulphurous 
waters are indicalctl. The amenorrhea uf stout subjects wituld 
first 1k' treated by an anii-obesily regime (Brides, Chatel-Guyon, 
Maricnbad). that of nervous origin by chlorinated soda waters. 
temitenxl bv the addition of the afore mentioned mother waters 
or bv sedative watei-s (Neris. Lu.Keuil. etc.). In case of subin- 
vululion of the uterus sulphurous waters arc suitable (Cautcrets. 
Switl Sauvcur) or mud Imtlis. 

O^tmrnorrhra has the same indications. 

Comgr^live mclrorrhtttfia of pubertij %vili obtain great Ijenefil by 
% H»wMl nl a smlium chloride spa; above all. in young girls who 
»iv wn nervous, great advantages accrue from treatment with 
Ukttbi vX feeble cona'ntratioii inixeil with an appropriate <puintity 
%tf WiMlker untcrs. 

,|f4lrt>rWiiiyi(i itcrurring at Ihf menopause is well treated by a 
Wtum vi Iwlhs at Bourbon-Lan<y' if there coexists an arterial 
iLvwttvwitm; *t Chatel-Gtiyon, at Brides, and at Saint 
^, ;r thvn- i* aUo abdominal plethora. 

-'• •' mfthii* should Ik- tn-ated with sul|jliurous waters 
^,. .<«>\isls with Ivniphalic manifestations, strong sodium 
\-i- ^twtvft. Fur chronic and painful genital conditions, and 
f,. ■' iitorA' de|M)isils, waters of indifTerent character 



HYDROMINERAL TREATMENT 97 

The action of sodium chloride waters on fibromas is undeni- 
able ; their employ is however contraindicated in cases complicated 
iiith cardiac troubles or fatty heart. 

To combat sterility most varied are the different waters 
suggested and good results which have been attained have 
resulted more probably from the hygiene observed than from 
any special action of the waters. 

In a general way, hygiene and regime, well observed, are 
powerful adjuvants to hydromineral treatment. 



PART II. 

TECHNIC OF OPERATIONS ON THE VULVA, VAGINA. 
UTERUS AND ADNEXA. 

CHAPTER I. 

SURGERY OF THE VDLVA. 

Suitunary. — Anatomical elements. — Treatment of traumatic le.sJons 
(wounds and contusions). — Treatment of inflammatory lesions (superficial 
and deep), of kraurosis, Icucoplasia, and pniritua vulvie. — Operations on 
the vulva, diminishing it (infibulation, episiorrhaphy, nymphorrhaphy), 
increasing it (treatment of agglutination of the labia, of strictures, and of 
vulvu-vaginal constriction). — Radical operations, excision of the clitoris, of 
iiillainmatory lesions, and of tumors (benign and malignant). — Treatment 
(if vafrinisirniH. 

1. Elements of Anatomy. 

The vulva presents the form of a median anlero-posterior- 
rU'ft, honlered on the right and left by two projecting pads, 
Uh" laliia niajora. When these ore separated, two smaller foldss 
arc seen, tlie hibia minora, which anteriorly embrace the clitoris 
iind in tlu! s[)a(.'e l>etwcen them is found the vaginal orifice con- 
taining' tlie hymen or its remains and the urethral orifice. 

Under the name of fourehette is understood the posterior 
(■ommissure of tlie vulva. The vestibule is the small triangular 
area bounded aTiteriorlv by the cHtoris, laterally by the labia 
minora, and I)eliind by the meatus urinarius. Anterior to the 
fonreliette separaling it from the vaginal orifice a small depression 
can be seen which is known as the fossa navicularis. 

'I'lic vulva is separated from deeply lying structures by the 
urogenital dj;ipliragm, which is peiforatefl by the urethra and by 
the vagina, ami contains, in its tliic-kiu'ss, the deep transversus 

Its 



KLEMKNTS OF ANATOMY 



99 



'muscle and wranchcs of the i.scIiio-[iuI>ic vessels and nerves, 
iUre internal pvidic artery with veins and atronipaiiying nerves. 
I in the suhstance of Ihr [msterior portion of tlie luliia nmjora 
Ire the vulvo-vaffinal glands of Bartholin, whose excretory 
tin«U o|ien on i\\e groove which divides Ihe hihia minora from 



( U. — Vulva of » virgin. In Uw dUseetutl «rca the eommunionliona ol Bw- 
•Ha'* tbnd «ilh the bulb and the munoka which eovor II vxternaU)- are v«ll*«en. 

IIk liyinen at the junction of the posterior third with the anterior 
t»'o thir<is of this gr(K>ve. 

Estemally and anteriorly to the vulvo-vagnial glands is the 
bulh of the vulva, wrongly termed the hull* of the vagina 
l*cause it is situated Ih-Iow tlie urogenital diaphragm. This 
l»iilb of the vulva, which has the form of a leech gorge<i 



100 



SUHOERY OF THE VULVA 



with hlootl ftiu! with its small oxlreniity In front, is coTeird ov« 
by the bul bo-cavernous muscle or constrictor of the vulva. 

In Uie fatty mass which ctmstitutcs tlie greater [mrt of tlie| 
labia majora are found some fibrous tracts, the terniination of 
the roun<l ligament, and .sometimes a prolongation of peritoneum 
known under the name of llie canal of Nuck. 






m."^ Mr. 



r-' 






^" 



^r- 



V 



l^/..-/'.- 



.^. 



R 



yS^' 



^^1 



y -' ''^■■ 



■ -:^i ■■^:^ 






'X-;'^ 



>^- 



'.\f>\ 






1^ 



/' 



^?'' 



t 



•\ ■<} 






(f> 



^i\ 



^' 



/ 






Fio. 8S. — Vertical an<l truisvuTBo itectioii of ifae p«l«is (ftfter Farabeuf)' 
TImi urnRCiiital dia[>limsin U with the TtaaoU »aA norvM it contuo* ia vbite. Abovt' 
it Me Ifae ile^er lyinic oriinna: V, va^pnA; U, utoriu: R. levator ani: O, obtuntor inl«r- 
Dua. Below ii rin> tliv vulva; C, oorpua rav«rno*um of ui« olltaria: B. bulb of tli« vulva; 
P, awUon of pul>c»- 

The veSusels of the tahia majora, above all the veins, 
very luimci-ous. The arteries come from tlie internal pudic.^ 
whirli gives two collateral branches, lite superficial perineal 
which ramifieit in the subcutaneous cclhitar tissue, the deep 
perineal or bullHir. which goes to ihc bulb of the vulva; and 
two terminal braiiehe-s, tlie eavernnUA artery which goes to the 



TREATMEXT OF TR-VVMA TO THE VtTIA'A 



101 




corpus cavcniosum of the cliloris, and the dorsal which goes 
> the surface of this organ. 

The veins correspond more or less to the arteries; they anas- 
mose with the plexus of Santorini and with branches of the 
lemal saphenous. They often dilate during pregnancy. 
The lymphatics go to the inguinal glands. 
The nerves come from the iuternul pudic. 

a. Treatment of Trauma to the Vulva. 
I. Treatment of Wounds of the Vutva. 

In principle, every wound of the vulva should he reunited. 
an immediate union having in this region a threefold object. 

1. To pro<luce a condition of heinostasis, because small 
wounds may give rise lo <^uile dangerous hemorrhages.' 

4. To ])revent secondary infection which may easily occur in 
a region »liere permanent asepsis is impossible. 

3. To avoid in the future the fornuition of faulty cicatrices, 
which may deform or constrict the vidvar orifice. 

Union is not always pos-sililc in wtuinds of the vulva. It i.s 
coiitra indicated in infected wounds. It is simu-linies iinjKJssible 
t^ reason of the size of the wound. It is important in such a 
ta« to clasclv examine tlie cicatri/.uti<rn. 

Burns of the vulva anil inss of .inbxtanre fofloit-iiig im aotie 
infiammafionn of the rcgiim (noma, couHueiit pustules of variola, 
rtt) demand s|M.fial attention. Very often grafts or secondar}- 
Mloplastic operations are indieatwl in order to assist as much 
M|»oNsibIe the cusnielic and functional processes of the reparation. 

2. Treatment of Contusions of the Vulva. 

Tlie contusions of the vulva, coming on during the puerperal 
lie or ajiart from it, are interesting from tlie therapeutic point 
of view if they lead to the production of a hematoma. 

Them vulvar hematomas^ often describe*! as thrombi of the 

' In pwticular U tkii the «>se cliiring pregnnnry. N'nrhmnrtior hint publUliod Uio 
•ry oJ * wonwn in wlinm ruptiin> of ii vulvar v»rix lu Tlii.- lust muiilli uf prugruincy 
llolii-rilcallifruin livnuirrhu^ in nn hour lllrriin. klin. Wack.. 1890, i>. !)09). Hfilc 

ivM •i-i.-ii dnth ootiiR on In 10 rDinuIn ai tlir rr«uU ot thp nipliire ul a v&rix du* to 

(Tfrnnwelions vt Uw Oliilolrii'iil S.nioly, LoiHlon, T. XL). 



"IVA 

_ --- iiii> of the vulva, and tlic 

_. It 'mlines oneself to seniring 
_ - • .■ : > important when these are 
- - ' ■- i :iie heniorrliajjic eollcction 
. ::'':i.>ion. 

■ -^^ t freely, evacuate tlie clots. 

■:rv it. beiiifT careful that the 

■ ■■-LiiTiinia eavity, in onler to do 

^■'..■1 rill lip after fresh hleetlinj;. 

- Ill' -.imtused and result of the 

.'tiot'orni jjauze. 

■ •;. vvhatover its size, make an 

.-..:»' in the most prominent part 
■■<■ . •> oi the hihia niajora. 

..,^_-^. . ;.daminatory Lesions. 
_ . .. * ^tt'ertieial or deep. 

,^__^ T-Mumtdtory Lesions. 

<AniceouK cifHis and fnrimrlt's. 
. . ; 'v treated on the same lines 

. -. ifonj: dialjetie. stout, and also 

. ,i>iiv irritate<l by a leucorrheal 

>• ''.oiis and local application of 

■n,. - t -leiirhlMH-lKKHl of the vulva in 

;f,*"il, " . ,-^-41 Uithinj; of the parts, usiiif; 

!'.«■'■'■ * -,1. tit,, and l»y the a|>|iIieatioii of 

^.^.yy ,1, - "* _^ -wti^iw'iit- l-<K-all>athinssof the 

„.|,j(.], , - -^- " ^^ .j^^iv-ations of powder and tale. 

y^\,\vh I, ' "*...!-»»* •* »''"''*' "' ''"vt-r. 1 in 30, is 



perineal 

two ternii ^.^-tf^*- l' i'"" '>rw""fll'"^ vulva, nut 



TREATMENT OF INFLAMMATORY LESIONS 



108 



Eczema is treated by llie ordinary means, not forgetting thai 
its origin may be due to n vaginal discharge iind the patient may 
be diai»etic. 

Eryihrasma, which generally attacks the genito-crurnl fold, 
is first treated with tincture of iotiinr, and when (h'.s<|uaniation is 
produced, apply talc powder to which a little salicylic acid has 
been added, 4 to 100. 

Vulvitis requires a special treatment varying according to 
the case: 

In seftaccous vulvitis characterized by a hypersecretion of 
sebaceous material, which forms a sort of membranous lamina 
on the internal face of tlie labia majora, the labia minora and 
around the clitoris, and leaving exposed below this lamina, 
wbeii rubbed off, a mucous membrane redder tlmn normal. 
For such a condition we prescribe local bathing of the parts, 
minute attention to cleanliness and soapy or .ilkaline lotions. 

In mucous vulvitis, where there is a hypej-secretion of mucus 
and where the patient complains of wetting herself, order cold 
lotions and astringents (calamine lotion, solution of alum, and 
sulphate of zinc) and the application of inert powders. 

Vulvitis complicated with vaginitis is treated as vaginitis. 

We now pass to the vulvo-va</iititis of infancy. It is now 
renignizC4l to be due. in little girls, to gonococcal inoculation. 

Its treatment should first of all be prophylactic. We should 
treat the discharges from which the mother suffers, and to avoid 
rtiks of contagion by towels and sponf^cs. also in hospitals the 
Mine themiometer should not be used for taking the tempera- 
lure in the vagina of a number of chihlren. Epidemics of 
vulvitis have been traced to this cause. 

Curative treatment consists in vulvo-vaginal lavage which 
sliould be made by the doctor himself witli a little cannula, a 
red nibljcr catheter, and a solution of permanganate of potasli. 
I lo 1000. The mother should be advised to wash the external 
parts well with a solution of sublimate 1 to 10.000 and in the 
intcr^'nls between the lavages to sejmrate the labia by placing 
hrtwccn thtin a tampon of antiseptic wool (boric acid or salol. 
He.). 

Combined with the local there should also be a general treat- 
nient (iodide of iron and sulphur baths). 



U)> 



, 1. 



vagina, result frcih 
blood collects in ll^ 

If the henijili ! 
asepsis of the ir; 
excoriated, other' 
subjacent niiiy ■ 

Jf the belli, 
stop the hlri^ 
sutures eoiii] 
away with II 

if the V 
union i.s (!.■ 

When 
earlv «ii'l 

in ill' 
of the 1 1 



In 



( 

as i 

ill 



|! 



.r"' accompanied bv t)ie 
;:!■: the uretiiral orifice, 
; uiiy simulate a criminal 
'p^uiaturc appearance of 
-ilver nitrate (1 to lUO) 



__ --.■ - 'ir^matnTY Lesions. 

::■■ labia majors should be 
f-, .IS also abscesses developed 
. -i:::ic hematoma, etc. 

■ ^ii'u of the vulva wliicli need 

■-■•iitfinal (jland of Harfhoitn 

"Ally 1h' limited lo the jjland 

-.:<• laliium. In any ease tbe 

- -r .e-if* extended incision ]>arallel 

; lii on its internal surface. .\s 

> •■ ;-.,:t:»usly. before tbe abscess has 

•: -jvity may l)e re<jiu'red aft4>r tlie 

■ ■ vrevent too ra]»id cicatrization. 

^ ■> not infrequent to see iistulas 

. ■ - -'!n still affected portions of the 

■ ,1 cure, we practic-e the complete 

liv;' flaw <luring the acute stajre; 

■:■■: liavs after the incision of the 

■o ■<-■;■. sliouhl only be advised in 

. :s at the outset of the attack when 

..■i'.> «ith a si>ftened center exists; in 

.,, ,■ ■> I'riiuarily or secondarily limited 

X .jrrit^l out in the same lines, as 
, . ,;, :"or the excision of vulvo-vaj^inal 



, ■■-c^nancv. because the suppuratini; 

\, ■ ■•■.cions of liarllioliirs gland may be 

■ 1-';; i>arluritiou and the dangers of 



TREATMENT OF INFLAMMATORY LESIONS 



lOS 



lion as a sequel to the operation are not as great as was 
riiUTly tlioujiltt. 

If Barlholinitis, has not l>een methodically treated, a fistula 
ly result. For simple fistulas, excision of the tract and 
ids suffices. For fistulas opening on the internal surface 
the vulva and the perineum, more particularly those which 
[ti-ntl to burst into the anal canal llie little operation we have 
'just, described is insufficient. It will be found neces.sary lo 
completely divide the perineum down to the level of the fistulous 
Iracrt which is then excised and then proceed to the reconstruction 
of tlic ]>tTineal body by one of the procedures wliich we will 
dcsicribe later on.* Spontaneous cicatrization always leaves 
an in5ufficirnt perineum. 

3. Treatment of Kraurosis aod Leucoplasia. 

Leucoplasia, charaeterized by the development of white 
plaques, requires a very simple treatment. .Avoid all causes of 
irritation and use alkaline injeelions. Only plaques wliich arc 
thickened demand excision, because one should always fear in 
such conditions tlie secondary development of cancer. 

Kraurosis («pai';to«ns, retraction) is characterized by the 
atrophic retraction of the skin an)) treated, in the majority of 
cases, by a purely medical routine (minute cleanliness, treatment 
of associated vaginal di.scharges, injections and washing with 
emollients and alkalines. etc.). Surgical treatment Is only 
rvquire<t In ca-ses complicated with persistent leucoplasia and 
disjiareunia.' 



4. Treatment of Vulvar Pruritus. 

As in all casesof pruritus, we must look for and /rea/fAecnMaff. 
This is at times quite evident: pediculi, intestinal worms, dirt, 
w Vaginal discharges. These last named may be very copious. 
To demonstrate the role they play place a tampon in the vagina 
■Oil the itching disappears so long as Uie tampon remains in 
place. 

'Ste PfritKonhaphy, 

'Jaylr. Vulvar Krauroala. Rniew^Gynewloifu and Abdominal SMrttrv,] 



SURGERY (IK THE VULVA 

Dial>etcH may lie the cause, by it.s hpmalogenous acdon or 
local irritation of the urine. 

Pruritus, rssontially, can only he aclmittrd after a vigorous 
March shows no otJier cause. 

Injwtions with very hoi Iwile*! water, or vaginal ovules 
containinff a httlc chh>rliydrate of i-ocaine (O.W to 0.03 centi- 
grams- 1/3 to 1/4 grain), or applications of silvernitrate I to 40, 
etc., proc]iiec a great relief. 

As to rail trcaltunit of pnirilu.s. it has differed according to 
tin* iiiea entertaiiuNl <tf the atretlion. Sanger and Kelly, who 
helieve it to he a derma to- neuritis, advise Uie excision of tlie 
placjueN at the seat of the ]>ruritus. Huge, who thinks it is a 
{Mira.sitic coiiditiun, advocates a simpler treatment. He wa.she-S 
and ('leans well with soap the cervix, vagina and vulva after 
which he applies to the last carholi/ed va.seline (3 to 4 per 100). 
He recommences his cleaning operation after a few days and 
aoon olitains a complete cure. Hirst and Tavel advise a 
reiiRClion of Ihv nerves involved in inveterate cases. 

4. Operations on the Vulva. 

Biime of the operations on the vulva are of slight importance 
and won't detain us. 

Adhraitmn of the prrpuee of the clitorin are jwrhaps accom- 
piiriied hy retention of smegma and verilahle eoneretions result- 
ing in eoUHctpu'nt irritation and niasturhatiun. These may l>e 
iie[>anileil l>ark l>y a little blunt sound after the prepuce has 
been dnnvii back toward the pubis and a little cocaine applied 
lorally. After freezing is complete, the cHloris. red and denuded. 
in Nniejin'<l over with vaseline and the motlier is ndvi.sed to draw 
luek Ihe pre|iuce of the clitoris daily, vaselining the parts so as to 
prevent the further fornialitm of adhesions.' 

Krchiim of t/if labia minora is practised hy certain |ieopIe. 
mieh as the .Maures, following a ritual similar to that of the 
Uiaelileji* cireunicisiun. Its pracU^-e for hyj>ertr«pliy is rarely 
t'lilletl fur. 

Speaking generally, the operations done on the vulva are 
itlvldii) into Ihrii- groups; 

■ lUpiMk, Ailluwiuti at Ui« KioaIo Prcftiioe. A nmc. Oyn. aiuf Obtltl. Jownal, N. V., 
(MH. 1 VI, t>. -iTtl. Kelly, p. «. Ov . >' V.. IWMf, 



OPEBATIONS ON THE VULVA 



id; 



1. O|>enitions to constrict or close the vulvar orifice. 

2. Ofrtralions to increase the orifice. 

3. Operations of excision. 



1. Operatioas Constricting or Closing the Vulva. 

0|M.'rolioiis for the constriction of the vulvar orifice arc tJiree: 
nliitulation, episiorrhaphy. and nymphorrhaphy. Strictly speak- 

injf, these three operations lielong to the iloinain of relros|>eelive 

surgery. 

This is ahove all true of injibuhtion wlii<'h consists in uniting 
fte labia majora by a metallic rinji;. Frequently practised in the 
middle ages, it still exists in Kthiopia, where it appears to be the 
rule to unite nilh an auiianthns wire the labia inajorn in little 
girls of one year to one and one-half years. At the time of 
marriage the mother of tlic prospective husband examines the 
future bride and her consent is not i^Rined until the ring is found 
to be quite intact. It is afterward incised with considerable 
potDp. 

In episiorrhapfiij^ the labia minora are removed and the 
interaa] surfaces of the labia majora are rawed and allowed to 
unite. Nymj}!torTliai>hy^ is an operation of the same kind, in 
"Wb the freshening; and suturiiijt occur in the labia minora. 
Employed in ca.ses of rebellious vesico-vaginal fistulas, these 
tno ojierations constitute a deplorable necessity, not being able 
to do belter, and are only very exceptionally indicated. The 
vagina is transformed into a diverticuhini of the bladder and 
Wotnes most frequcjitly the seat of calculi formation necessi- 
Uling a secondary' opening of that which has l>een closed. 

2. Operations Enlarging the Vulvar Orifice. 

Treatment of Adhesion of the Labia. — The simplest of these 
opcmtions i.1 that in which the laiiia arc separated by a grooved 
uund. The condition of the adhesion of the labia is brought 
•bout by a congenital lesion, or following on an infianiniation 
"liicb has caused a disappearance of the surface epitliclium 



' Of tmrtiBV, b: 






miiuira. 



OPERATIONS ON THE VULVA 



log 



mche.'i) from the border of the vulva, and in the saror plane as 
the cutaneous incision. 

A few forceps having In'en iipjilictl uiid heiiiostaKis secured, 
iufficieiit access is afforded the surjjeon to cam- oul the operation, 
which is finished by suturing. 

If he wishes to reestablish tlie parts as before, he commences 
by uniting the perineal and vaginal segments with a stout 
thmtd of .silk or silver in the line of the small axis of tlic diamond- 
shaped space created by the incision. This suture passes l>elow 
till- bleeding surfaces, so as to obliterate any virtual cavity. He 
then sutures with catgut the vaginal mucous membrane and 
the external parts with silkworm gul. 

In cases where a vulvo-vaginal stricture exists, as has been 
oliserved in certain vesico-vaginal fistulas, it lias been found 
better, after tying the vessels, U> allow tlie wound to cicatrize with- 
out intervention, or else suture it in the following way: Itmay Ijc 
sutured jHTpendicularly to the direction of the wound, and we 
commence by placing the first stitch in the long axis of tlie 
lozcnge-slui[jcd space and suture the vaginal nuieous membrane 
to the skin and then suturing to the right and to the left the rest 
of the wound, until the skin and mucous membrane of the 
vai^ina are united. In this manner we obtain, as our experience 
lias taught us on many occasions, the healing of the vulvo- 
vn^'iiial strictui'e, having first made use of the incision as a pre- 
licninarii' portal of entry. 

Side by side with the vulvo-vaginal incision we should mention 
the procedure employed l)y Mi<'haux, which is a latvnil j)crinf~ 
olomy combined with a vulvo-vaginal incision. Michaux makes 
an i*chio-reclal incision about 10 cm. (4 inches) long, parallel to 
iHc intcrnatal cleft and a good finger's breadth above it. The 
ini'ision commences posteriorly about the level of the anns and 
terminates where a line between the ischium and pubis crosses 
Iht labia majora anteriorly. It is deepened until it just comes 
uito contact with tlie external surface of the vagimi which is 
"iPwd. We may continue, if necessary, the incision as far as 
toe vulva and in this manner succee<] in making a vulvo-vaginal 
cleft. 

The indications for division of the vidvo-vaginal tissues 
appear to us to be yen.- restricted. As a preliminarj- to vaginal 



110 



SURnERY OP THE VULVA 



Iivstoreclomy it should he completely rejected. If Uie size of the 
tumor or smalhirss of the vagina n'lider impossible the removal 
of tlic uterus by the vapnal route, it is much simpler to hnve re- ■ 
course lo abdominal hysterectomy or lo remove it in fragments. 
VulviHvaginal splitting, however, has its use in certain cases of 
perineal dystocia and in certain uterine operations in virgins, for 
the renmval of certain vaginal tumors and finally for tlie treat- f 
ment of certain vesico-vaginal fistulas which are difficult of ac- 
cess, particularly tlii>se that cxtcnil high and are complicated hy 
cicatricial contraction of the vagina. 



I 



3. Operations for Excisioa. 

We will •succo.'isively .study tlie excision ojM-rations for inflam- 
matoiy lesions and neoplasms. As a preliuilunr^' ne will say a. 
word or two alwut the removal of the clitoris, whether this 1 
normal or simply deformed, because the indications for i 
removal are ijuIIp S]>r<'i:d. 

Removal of the Clitoris. — This has been rccommemlcd in 
cases of hyslero-epilepsy (Baker-Brown). It has given no 
result as has also been the ca.se in treatment of masturbation. 
Is one authorized to interfere with the clitoris of a child which 
is abnormally developed ? It can hapfien tliat an exaggeriilion 
in the size of tlie organ exposes it to friction of clothes, etc., which 
may lead to ma.sturlMition. In short, the only indication for thefl 
removal of the clitoris is hypertrophy when it is enlarged to 
such a degree that it simulates a penis (a variety of pseudo-her- 
inaphrtMlisui known under the name of gynandrj')- Independent 
of its inconvenience the hypertrophy may be a cause of annoy- 
once in the accomplishment of the sexual functions. 

Another indication for the amputation of the clitoris i: 
carcinomatous degcneratii»n of tlic organ. 

The ojierative procedure for tlie amputation of llie clitoris 
is very simple. Dissect up from the base of the clitoris A little 
collar of mucous membrane and then cut transverselv across the 

* 

erectile cylinder of the organ. This sectiim cau.ses a slighl_ 
venous hemorrhage which two or three catgut sutures placod^ 
around the fibrous envelope of eavernous ti.ssue will suffice to 
stop. The mucous membrane is afterward brought over tlie 
little stump and sutured with silk%vorn] gnl. 



1 





owe excise the sclerotui area, iimi 
•^rtuiuly follow. 

Lufifix, of wlik-li the rodent ulcer in Gerrnam- constitutes 
link- a variety, should l>e treated l»y entire reniovul followed by 
'itoplasly.' Severe forms of knmrtMiii- should be treated in 

, ' 8«« (urtlMT tlio rrmflvnl of mal'Knaiit tumoni. Wlicn loial cxtirpstioti i» impotaible 
jatlce^l eoBililinn mn hp inipntvi<(I liy timotiiriK <i|i nith a rvil eouluiy or upiiliuatioiiii of 
""Wkcid, mincviitritlc>l xkIuIiuud uf vhluriilr iif linc. etc. 

'01 Rn ciucrfl opcntiiii lir Mikrtin, (nut nlitninoil u dpiinitc compl^to riire, kdiI only in 
*W Om dkl tie Kut II iTCiirprmT, An rxti'UMvi; t.<xlirpatii>ii irill u|ii'ratv nt;uinHt thi* 
JxiyRwUon. S« kniuroH!»: Arni)ii.\, loiitnlmiiiin A IVimJn du krwiio«U vulva- 
""•^, 1808-18119. No, 621. Jnylf. ICr.i-».- lif (iynftolvstr. V»n». IfltW, p. (W3. 




112 



SimnERV OF TUK VULVA 



Ihe same way, and leuatplaxia with thickening of the <iWwc*.' 
Klephuniiusis of the vulva is also a cast for extirpation. In 
such eases it is at times veiy extensive and yet it Is exceptional 
to have trnulile in a reunion of the tissues. However, lietnostnAis 
will <leinan(l dose attention, as hematomas may so easily form 
ami yield to sn])])nrution us the preliminary' cleansing of thv 
elephantiasis masses is so difficult.' 

Extirpation of Vulvar Neoplasms. — From the operative point 
of view these tumors can he divided into two main groujw: 
Benign tumors and malitjnant tumors. 



I. Treatment of Beniga Tumors. 

These are nitanfaux and xuftrutmieoitg. 

1. Cutaneous Tumors. \'e<jetutwns.~Vegetations occur 
fre<]uentiy of cutaneous tumors. Commence their treatment 
tlie attention to their causative agent, tlic discharge, and using 
astringent pow<ier such as alum. These means are generally 
insullic'icnt and so one is most often ul)lige<l to have recourse to, 
surgical inter>'ention. 

ICxcision with scis.sors is only necessary for extensive vege-I 
latioMs which possess a tliick and resistant pedicle. For othersi 
the sharp curette suflTices. 

It Ls necessar\' to stretch the skin well during llie little o[M-ra- 
tion, so that the vegetations only are remove*! without imdue 
scraping of the surface of the skin on which they are implanted. ■ 

Having finished the curettage, lightly tonrh up the bleeding" 
points with the thermocautery at a dull red heat. This sii{H'r- 
ficial cauterization prevents bleeding and prevents a return of lh< 
vegetations. 

A little iodoform powder and the application of a wisp^ 
of wool suflicv to cure the condition which leaves, in healing..^ 
no cicatrix. f 

This extirpation is so simple that we advise its execution 

' Poiffa do MaituudMui. Costribution k I'^tudp do U li>ticaki!ntt4>M< ntlvu-VB|:iiiak>. 
Tk. it Pari*. 1804-1897, Xo. GSS, Bcx,LeucafiUalt«etCiUiiiniI(lo«U«Umuquirit« i-ul- 
vo-nniiak. Th. dt Pari; 18S7~ISJi8. 

■ Om muat not cobfoiind iruo ck^plianllMlii of Iho vulv» with panido-cle|ili*fiti*Mi, 
wtilcfa {■ • *or1 (it iiidiiratcil nlomn ■ccmiipniiii'ine cvrlivin uluproiu IctioiM, more [wr- 
ttCuUrly ■ypbilitic Iphiodi. and whicli, iludf|>rarin|t a-itb tlie c«ui«l acent, an iwvtr 
jiutilUbl* ol oprrativo procedure. 



r- 

1 




OPERATIONS ON THE Vl'LVA 



113 



urinp the course of pregnancy when such vegetations may 
during liL)>4>r itc a Hource of complications.' 

ifoHitxcHin. — The name of molhiscum of Ute vuUia should be 
limited to the cutaneous fibromata of that region. The-se tumors 
arc most often pcdiculalcd. The simple seelion of their [K-dicle 
with or without preliminanr' ligature may lead to a cure. It is 
better perhaps to extirpate their base of implantation utid to 
unite with two sutures. In such a case as Jalaguier had, the 
tiuJiim'um was continuous with a subcutaneous fibrous forma- 
tion which extended to the neighborhood of the ischium aud 
causeil a veritable dissection. 

i. Subcutaneous Tumors. — These tumors are fluid or solid. 
Tliey may lie limili-il to the vulva or extend to the neighboring 
rvgion. 

The tumors whioh extend to neighboring regions are saccular 
e^aandct/slsoflhe perituneuldiverliculunntrc&nalofNiick.^ The 
extirpation of this category of tumors is comparable to that of a 
hmiinl .tac. It may be necessary, after incision of Ihe tissues which 
cover them, to open the cystic cavity, empty it of its contents and 
extir|>atc its wall and, taking care to remain in contJict witli its 
internal wall in order to avoid losing oneself in the more remote 
plwws of ch-avage. not to injure Iho vessels or neighboring parts. 
Amoag the cystic tumors limited to tlie vulva, the extirpation 
prcjcnts nothing of importance. They are simple cysts and 
ttbaxeous cysts. Otliers, such as cysU of Bartholin's glands, 
raeril more attention. 

hi order to expose tliem, we make an incision along the most 
prominent part of the tumor, following the axis of the vulva 
to the limit of tlie great and small labia. The cy.st being thus 
taOfed is dissected out. being careful not to perforate it, and 
winning directly in conta<-t with it so as to avoid perforating 
Otemally the lining of mucous membrane which is sometimes 
^n thin and dfmbles the wall of the C)*sl; externally beware of 
•Bjiiring the bulb of the vulva and transverse [wrineaj artery, 
nnish the ojieralion by tying all the vessels in order to avoid the 
lonontion of a heuiatonia by in.serting some buried catgut sutures 
>ini in suturing the integuments. 

^ ' l«r*r (A.), Contribution h \'6i.\u\* 6m vtetftaUooa ohei leu tvtatues enodnUs. 
'^APvii. ISeS-lSW. No. 4«2. 

'WadMlmann. ArMwf. klin. Chir., Dorlln. 1800, T. XLIII, p. S78. 




114 



SimOERY OF THE VULVA 



In cases wluTe Ihc cj'st presents some difficulty of exlirpaUon, 
open it, curette its internal surface, and paint it with a solution of 
nitrate of silver 1 to 5, chloride of zinc I to 10, and tampon with 
a swab of iodoform j^auze. which is left in phice until saturated 
with pus, renewing the tamponing cacli dav in such a way as to 
keep the wound open until filled up with pranulafions. 

The solid benign tumors limited to the vulva (liponiatji) or 



JC..V 



Fia. 88. — IncisioQ to expose the gland of Bartholin. 

extending to neigliboring parts (fibro-adenomata of the round 
ligament, perineal myxo-filtroniata) present no particular diffi- 
eulty in tlieir removal.^ 



II. Treatment of Halignant Tumors. 

Epithelioma.i of iiir^ imlm'^ should hv. removed willi the knee 
"en bloc" together with the ganglionic accompaniments. The 

' Maucluire, Mullusvuiu ptuiduliui] (1« U vulve. Annaltt'Itgijnltohjiie.PMh, 1M3, T. 
n, p. 400. 

'Teller tRtcl>Htd). Vther das VulrakarrioQom. Zeittck. /. (M. u. Gyn., StuUg&it. 
1007. T. LXI. p. 3CH). 




OF VACINISMUS 



115 



iH by aiitopIa.sti(! proceciurcs. The 

■ - to sec carefully to Uie repair of the 

liimor o«'Upie.s the region of the meatus 

■(■ [ijiticiit will not be exposed to com pi i- 

(:iiT striclure of the new urethra (see 

ma is inoperable, a palliative treatment is 

he thigh.s with an ointment (vaseline ami 

The loeal irritation is produced by the 

■tig discharge coming from the ulcemtion. 

• should tic washed with antiseptic solutions 




lui. yi). I'lo, PI. 

!■> and katnpliuty nficr exlirpntion of the kiit4>rior part of tho 
vulva ia[t«r KoUy). 

owden'd with iodoform or even, in ease of bleeding, 

iif it being covered with sphacelated granulations, to 

>me surgeons, following Kraske. advise the appHca- 

liineous flap to the ulcerate«l surface after scraping.' 
i>plionally one may be called upon to remove a cancer 

t's gland. ^ 

5. Treatment of Vaginismus. 

liKinns is characterized by a painful reflex coiitrnction of 
ptcr of tlie vulvo-vaginal orifice. It involves the sphino 

: Untr mal. Woch., 1RS9, ji. 1. 
i::>. I'll ciuo ill parniiDiiiik drlU ginuilola dpi Ttarloliai, Arthiviodi 
..I..srui. N«|>nU. 1WHI. T. Vll, No. 4. 





Ill cases where the cyst presents 
open it, curette its internal surfuce, a\^ 
nitrate of silver 1 to 5, chlonde of zi^ 
a swah of iodoform jpnizc, wliioli is 
with pus, renewiiif^ the taiiiponiiij^ e; 
keep the wound open nntil filled uj) ' 

The solid lu'iiigii tumors limited 



II, p, -100. 




Fig. SB.— Inddon to «xpow i 

extending to neighboring [Nirts (fi| 
h'gament, perineal mv-vo-fihroniata) 
cully in their removal.' 



II. Treatment of H 

Epitheliomas af Uic vidva' shot 
'en bloc" together with the ganj 
UaucUin-. Molluftnum pttuiluliim tl« Ik vnl 



'TeUcr ttticbnrd), U«bor cJm VulvnUnioe 
1«(U, T. LXl. p 309, 



!ATMENT OF VAGINISMTTg 



117 



devised. Ail incise the skin, expose the conslric(or. cut a por- 
tion of the fitM-rs, and tear acrus-s what remains, anil finbth with a 
suture of the cutaneous incision. 

Pozzi, after excision of the hvinen and forcihic digital dilata- 
tions of the vulvar orifice makes on each side an oblique incision 
of S to 4 cm. antero-posteriorly, which goes inncli hcyond tlie 
hymen. lie notchc-s the constrictor, dLssccts up the lips of the 
incision and unites it at right angles to its original dissection; 
thus one can obtain at the same time an increase in size of tJie 
vulvar orifice and an e%'ersion of the vaginal mucous membrane, 
thus submitting to the friction of coitus that zone fn>m which 
refiex actions spring.' 






> 



Flo. 92. Pia. 93. 

PUuilic operation tor raginisuus. 
In FIfC. 92 on one aide tbe ineinon whiob giutt snmc diHtanoe beyond ihi^ hymen x&d 
nil Lb«^ otlicr *idv Ibe opoa vound. In Fif;. i>3 the lips al the iiiriAion nrc ditMOCU^ up, 
(L* ctir»»»rictor notdMxl Mid the ojwration Mmiiriftlei.l riy suturt-. 

4. Resection of the Internal Pudic Nerve.- -Tavcl advises tlie 
fallowing procedure: About the middle of the space which 
separates the tuberosity of the ischium from the anus he makes 
an incision alwuit 8 to 10 era. (3 1/4 inches lo 4 inches) long, the 
direction of which is sagittal and of which the exlremity corre- 
sponds to a line joining the two ischia. 

After having divided the skin and sulvcutancous fatty tissue, 
one proc'ee<is externally and posteriorly toward the internal face 
of tlic i.schium. In this manner ontr avoids injuring the inferior 
hemorrhoidal nerve, which comes out at the level of the sciatic 

■ Veil cuU aCTOM lli« UiteKumriiU mid tli« ronslriutor of tlu) vulva hy «i incirioo 
nwtitttinit [ratD Uie vulvar orifW. Th«n lid trnnafnrini hia vfirllcal incision Into a Irana- 
■^ ofM< by TCtuiitinK thin vngiaul ntiicoiiB nicmbrani^ lo the «kin. 

[tayeii inctwa the lour«li«t1<' t rniisvcniely lo tJiu i.-xti.-iit «f 30 to id ram. lliiii incl- 
_. a U iiimI* In one cut wiUt a binloury or liy snvr-ral outs wiili n tiT.rftiKlit •ciMon. Ttw 
■AUsior tip of Um wound i* tlwn Hoii^d in » pnir of rinjc-bltidi?d (oro«pK and Mparat«d 
triMn Uw MiblMWnt Umum to « d«pth at about 30 nun. The aphinctcr betag thus 
KxpMMl U iaeaed tntaaverMly. 



118 SURGERY OF THE VULVA 

spine. Through the fascia which covers the obturator intemus, 
one can feel the palpitations of the internal pudic artery. The 
aponeurotic sheath which surrounds it is split and one can then 
isolate the nerve from the artery and accompanying veins. 

It is also imperative to distinguish the various branches accu- 
rately in order to preserve the anal subdivision of the perineal 
branch. In order to do this pass a sound under these nervous 
filaments and this will provoke contractions in the corresponding 
muscles ; the sensitive branches can be recognized by the fact that 
traction exercised on them causes a depression of the points of 
skin which they supply. 

After having cut the nerves as far back as possible, the per- 
ipheral end is taken in a pair of Kocher's forceps, and turned 
round and round on the forceps, and its terminal portion is thus 
completely torn out. This withdrawal is limited to the branches 
which correspond to the hyperesthetic area. 

The edges of the incision are reunited without drainage in 
order to avoid the very frequent secondary infection which occurs 
in this region. 




CHAPTER II. 

SURGERY OF THE VAGINA. 

' ratmcDt of traumatic lesions (wounds, hematomas, 
— Treatment <rf inflammatory lesions. — Treatment of 
I malign an t).^l>eatment of strictures and atresia of the 
■ tiitii of neo-vaginas. 

1 . Treatment of Traumatic Lesions. 

1. Treatment of Wounds. 

'Wlien one is confronted with a vaginal wound, one must 

(iiire first into the conditions which produced it. With the 

cption of operative wounds, the causes ordinarily met with are: 

jiinal abortion, coitus,' tailing astride an object, and finally 

mchements,^ during which tears of the vagina occur espe- 

^Hally at the two extremities, injuring at the same time the cervix 

lilcri and the pecineum. This is explained by the fact that the 

vagina is more supple, and more capable of dilatation at any part 

of its course than at the two extremities. 

The treatment of these wounds consists of two separate acts: 
to slop hemorrhage and prevent infection. To fulfil these condi- 
tions the best course is to suture the wound. 

After evacuation of the clots and cleansing of the vagina by 
* copious irrigation, one should methodically examine the wound 
with the aid of specula. 

Suture it with catgut and place a tampon of iodoform gauze 
in the vagina. Tamponing without suture is only used when 
nothing else can be done. 

When the wound is complicated by the presence of a foreign 
»ody, the removal of the same is indicated. Generally easy, it 
tnay be very painful if the body is engaged in the wound and 

„ ' N'eueebauer (F-), Venus cruenta violans interdum occidens. Monaiichr. f. Gtb. u. 
Cyn., Berlin, T. IX, p. 221. 

'Morel (J.), Rupture et perforation de la paroi posWrieure du vagin pendant I'lic- 
Muehement. Th. de ParU, 1897-1898, No. 35. 

119 



1 IN 

spiiio. 'J'Iin)ii;;li ' " ninvfiiiciits of lis 
Olio can feel lln- 

apiniciirolK- s\i< ■■ wouml. invnlviii;,' 

isolate Wiv nr]\ -'• pentoiiitis, a lai-iri- 

It is also i- 
nitcly ill on I 

)>]-aii(-h. In - ~...~is. 
tiliiineiils ;i; 

n,„s{.|es:l' :.-:iiii:msli v!.>,ri„.,i tV,.ni 

t,.actioii . ■■'?-' ^'" ''1^^' t'"' <'lli"''-^- 

^ki„ „l,i, "-»f "fit'" IVSi.Iv.' S|,UII- 

^fl,.|. . .iraiii tin- as4']).sis of tlif 

ip],P,..,| . " :0 fti'usioii wlicii lliis i-i 

roiiml , 

(.oi„.,j, ■..lUtma l>y ciiiilrinialioii of 

^^-|,i,.|, li'i iiulicato, on tlir <on- 

'j _. _ "iMavity ill the first inslanco 

fyy^\,. ' "-•*' inlrapolvic IitMiiatninas. 

-^i-iion is already SDincwIiat 

- _-^'-isivfly (Ifvclopinir lu>iiia- 

-. • ■ iUHJoniinal route. - 



III 



. ■;rs:jn Bodies. 

■:y ite divided into avoMaMc 
.. intntdnced diirin<; nia>|iir- 
■ iii.ii halHi's de.seriptioii. 

■ :;;eir presence vii|iinal in fla III- 
■ ■ „- -onietiines to strictiin's and 

■ J .Mvities (liladderand reetnnii. 
. I ..-:> arrive, sejdie troiihles, eti-., 
Inllu'seeundilioii.s treatmenl, 
.■\'i (lie simplest. 

■ -.'-x jiiri-'uju bndif. To do this 
v. ■■-• :t and then attempt exlraclion 

. , ■.■■■. .'!i the tinj,'er. 'I'liis extraction 
, . --. ' ".0 I'V reason of llie nature and 
■■ ■ -.1 iviit. T, l.xrii. ]., i;i. 

. ■■-..i T'l'lii'iiiiii; l.:ilmr iii>t Ansiu'luli'-L w'l-Ai 



TREATMKXT OF INIXAMUATURY LESIONS 



121 



pontJon of Ihe foreign body, of lis bulging into the viiginal whU, 
or bt'cause of the hymen or a cicatricial structure of the viif^ina. 
One occasionally has to pick it out piecemeal with a. cutting 
forceps or witli a Gigli saw, having first fixed the body with a pair 
of strong forceps. 

Hiiving removed the foreign body, disinfect ihe surrounding 
parts, and if necessarj" touch up the idcerations with a solution of 
silver nitrate (o per cent.)- A;; a final act treat tJic vaginitis and 
repair any fimtiila produced, 

2. Treatment of Inflammatory Lesions. 
Treatment of Vaginitis. 

The first point in the treatment of vaginitis is to inquire into 
ito cause (foreign body, uterine catarrh, cancer, prolapse, mas- 
turbation, etc.). As to direct treatment of the vaginitis, that will 
vBrj- according to its nature. One point of importance is to 
tnlcnlict all sexual communirution whatever be the nature of the 
vaginitis and simple lavage of boiled \vater will suffice in vaginitis 
tmplicating ^rregnancy. For mycotic vaginitis, injections of 
nilfjiate of cop|>er 4 [ler cent, in tlie treattnent of choice. 

In acid leucorrhca. one should prescribe injections of bicarbo- 
nalc of soda, an ainjile soupsjxionful to a liter of water. In 
/duf leucorrfi-ea, Labarraque's solution is frequently employed 
in a strengtli of 1 to 3 soupspoonfuls to a liter of water. In 
tiiToftic vaginitis it is useful to combine feebly antise[)tic injec- 
tions (sublimate 1 in 4000) with the placing in position in the 
t^na of tampons impregnated with a mixture of glycerin and 
laonin or alum, which is left in twelve to twenty-four hours and 
iwipwed twice a week. 

Gonorrheal vaginitis necessitates a more serious treatment, 
louring llie acute |)eriod, rest, baths, and feeble injections of [>er- 
manganate of potash (1 in 4000), absolute cleanliness of the 
external genitals, which should tic wasluil three or four times daily 
•iUi a solution of boric acid, and oftener if tlie discharge is abun- 
^l A little later injections of 1 in 1000 corrosive sublimate 
solution preceded by a tliorough cleansing of the vagina willi 
•"•pand a thorough lavage with water. It is even better lo pla*^ 



122 



SURGERY OF THE VAGINA 



a tampon of frlyc^'riii and tannin in Ihr vagina the Hay previous 
to tlie injection. This causes a sheddinj; of the most superficial 
layers of the epithelitini. The suhiiniate acts l>e(ter on Ji mucous 
membrane thus treated. After washing out lite vagina well with 
sublimate, it i.s .slightly tamponed ivith iodoform gauze to prevent 
eonluct of its walls. 

It has also t)een advised to paint with a lU per eent. solution 
of silver nitrate. After having cieaneij the vagina well, one paints 
its walls with a tjimpon of wool soaked in this solution. Com- 
mence at the fundus and leave no spot untouched. Use tliesjiec- 
uluni to aid tliis procedure. Then remove the excess of solution 
with a piece of dry hydrophile wool. Next coat the vagina with 
vaseline and place two tampons, furnished with silk threads, 
in such position as to prevent the folds of mucous membrane 
coming into contact with each otiier. The tampons are removed 
in forty-eight hours. 

It is quite evident that in this variety of vaginitis, more than 
in the others, it is necessary to attack the gonococci wherever they 
may be, whether in the cervix uteri, urethra, or in the peri- 
urethral passages, as vaginal reinoculations may occur with the 
greatest ease. 

I-jitterally, landau has advocated the employment of yeast in 
the treatment of gonorrhea. He Mashes the vagina with sterilized 
water, and then introduces into the vagimi two teaspoons of yeast 
and one teaspoon of grape-sugar. A few minutes after he intro- 
duces a tampon saturate<I willi grap«v,sugar, which is removed by 
the patient in eight or ten hours. These applications are made 
ea('li setrfuid day. 

In a general way. for all varieties of vaginitis one may utilize 
three methods of treatment which may be sometimes of interest 
to combine. 

1. Painting with somewhat concentrated solutions of active 
substances. 

2. "N'aginal injections. 

3. Applieation of tampons of glycerin i)lus tannin (1 to 2), 
alum (5 to 100). ichthyol (.5 or 10 to 100). thyenol {i to 100) or 
protargo! (2 to 100), ete. 'I'hc patients, when left to treat them- 
selves, are allowed to introduce glycerinated ovules, to which 
some active substance has IxH-n added. 



TKEATMKXT OF TUMORS 



123 



3. Treatment of Tumors. 

of the vagina may he removed: 
tivclly /w vies naturales. 

ftcr division of the vulvo- vaginal tissues whidi is carried 
the liealthy side (Dulu-sscii) or on the diseased side 
or in the median line (Thomson). 
fler transverse perincolouiy (Olsliausen). 
Bv the saeral route. 
By the ahdominal route. 
0. By the conil»iiialion of both tliese routes. 
7. By the paravaginal route. 

N'tinc of these rtnites should lie r^'garded exclusive of the others. 
TTie nature of the operation depends on the tumor with which 
one is dealing. 

1 Cysts,— Cysts of the vagina, small and non-infected, are 
renioveti "in toto" per vitis naturales. It is the oiK>ration of 
dmioe, hut if the cyst is large, with pmlongations into the broad 
ligaments, as in certain congenital cysts, the total extirjNition of 
tlir sac is impossible. It is therefore necessary to confine one- 
kU to incision of the cyst, excising its prominent position and 
niluring its base to the sides of the vaginal ineisi(m. 

.\fter having curetted its epithelruin, it is well rubbed over 
*'ithii |»ie<f of wool hi'ld in a forceps anil soaked with chloride of 
URc solution 1 in 10. Afterward the cavity is tanipojie^l with 
wdoform gauze and healing occurs gradually by healing from 
l»elow. 

Suppurating cysts arc treated with incision anil drainage. 
i. Fibro-myomata.- The extirpittion of these tmuors is 
"studly' quite easy. 'I"he treatment of choice appears to be: 

A. Incision, then enucleation followed by two layers of su- 
hjpps, a su]>erficial and a deep, in cases of sessile tumors. 

B. Ligature of llie ]>etlicle in polypoid tumors. 
.\s these tumors frequently spring from the anterior vaginal 

^11, torsion should not be applied to them, Lieeau.se that may 
Wd lo a tearing of the bladder. 

In such eases, llie volume of the tumor is such that, in order 

_ < JKoMe (P.). Dm Fihromn icuilpR «t pMiciili!* 4u vtipa. Th. li* Pari*, 1M)8"I909. 



124 



SUIUllillY OK THK VAGINA 



to disengage it, one frequently has resource to obstetrical forceps 
anti tlic Imnd introduced into the rectum. We think it is simph'r 
to take awjiy the tumor in fragments. 

If the fibromyoma is jjaiigrenous one can, after extirpation 
of the tumor, pack the site of enucleation with iodoform gauze 
and allow it to cKks*" graduiilly up. 

3. BJalignant Tumors. — Malignant tumors have been removed 
fCT viax naftiratea or nialdng a larger aw'ess by a vulvo-vagi- 
nal division carried out on the healthy side (Duhrssen), or 
on the diseased side (Thorn), or in the posterior median line 
(Tlioinpson). 

In order to get better access, Olshausen advised a transverse 
■perineotmmj , dividing the pi-rineuni and then resecting the vagina. 
A. Martin is accustomed to do a total colpo-hysterectomy by the 
lower route. 

The immediate results have generally been good, but time 
has shown them to be di.sastrou8. In almost all cases, recurrence 
has taken place in a few months, and death before the end of a 



veer. 



I 



The progress n*alized by the extirpation of cancer of the 
cer\'ix by the abdominal route should fatally lead one to the 
extension of one's o[)eration to tlic total eon<'oniitant extirpation 
of the vagina. This is already the case. The uterus and vagina 
have been extirpated by the alidomcn in cases ui caneeroiis degen- 
eration of the latter.^ It is also possible to operate by another 
route, and to have recNjnrse, as already stated, to the simultaneous 
exlir[)ation of the uterus and the vagina by the paravaginal 
inci-iion of Sehuehardt.* 

We do not yet know how these mon; recent operations will 
result, but considering the frequency of recurrence in* the retrial 

■ KtOiuKi Archiv far Oyn„ Berlin, 11102, T, L.^II, p. 38. Bonn«fous, ContributtOD 
k l'*iudi' Jii uttin'M [iriiuitif till vafcin. Th. dc Pan: I!hi2 - I1KI3. No. 8S. 

' VtAt hna (ipnmt(;(l (unr rnuM in the followiii£ WHy: H<t makes n Riraiilnr tDci«ion 
inferlorly around llio vuuina. bL-uurot<!« tli« lissuts up ikiilvriorly iu< fsir ah the iwrvix 
Uteri, and puAluriorl)- lu fur u the iiouch of DoukIiib. He then close* tli* vagiiin by » 
«tn>ng auture ami finislxvi by lh« ftbdoinen, rotnoviiifc iitoniB nnd vaginn. folloiriDg tbo 
tuii:>l Wehnic ('mplorwi (or oanoen of tlie cervix. He hnn opcrntwl four times vrith 
thrt* currw »ii<l one dt«Ut. (Haadb. der dun.. Wipabadt-n, 1902, second edilion, T. Ill, 
Pari 1, p. 307.) 

' llnrtmann, Ann. J0 Cv<i«C-, 1909, 11. 756. 

* Unc of tli« feu' ctkoe^ known of cure bclonftsto Liiuunifti^in, II wtma woraui OpenMd. j 
OQ July 12. l&SS. rFuui.'ral4Kl in 1S(12 with occnrmndt! tin llic uorvix iitcri. Sfaa iru Men 
aipun, cumd in 189^ tI.«uouxloiu. Zur optrativu Bcliaivlliiuic dc* primArcn Soheideii 
Cordaonis. D«ul»eh 'Zeilsclir. /. Chir., 1S95. T, LXi. p. 411. 




lATMENT OF 'niMOHS 



125 



lite inexplicable from the direction of the 

lich tend toward the hypogastric ganglia, 

arises if the new interventions can give 

iiiy gynecologists have not hesitated to do 

turn at the same time as a coipohysterectomy. 

lenninated perhaps with an artificial anus in 

ninnielfarb).' or a perineal anus (Prj'or).* 

! an innperahle cancer, palliative treatment 

"■i of the i»art followed by a thermo-cauteriza- 

i;; with iodoform gauze. Kronig followcti this 

f with a |>rcgnant woman, arrived at full term. 

1 .ii-couchemcnt without any trouble. We believe 

(n n (Vsarean seelion in .sueli a case. 

I'hemical caustics have been employed, par- 
nidtloritk of zinc (50 to 100). 

Mvi.ses colpocleisis. This remedy appears to us to 
Ihe disease, hence %ve reject it. 

Etment of Stricture and Atresia of the Vagina. 

!|o recent times atresia was always supposed to be 

rilh an error of development. From the work of 

I* an<l Pincus." it would seem that atresia is most 

d, and particularly if Ihe uterus is well developed, 

cunsitJcrtKi as the result of a pathological process. 

conception of gynatresia makes u.s tliink of the 

' Ji pmjt/iylaclic tratUnttii. 

»w-bom female children of gonorrheal mothers, we 

a treatment to the genital organs similar to that of 

the eye and make a more or less careful antisepsis of the 

hw should carefully treat gonorrliea of new-horn infants 

lutely examine small girls affected with an infectious 

or grave constitutional tendencies, which may 

(wit. Contrib, au trsit ondntkiira du oiuiocr i>riinitif du v^gin. Rn: <U 
I. IWIT, |>. 5»9. 
[A" f^|«e^lIion for Prinuvr)- Va^niU CnrctnotnA. AiDnriciin (lynec. So*,, 
noi'/n Mf4. and Suri/.J-rurnal, Ontohcr 11. ItKH]. p, 373. 
' — lvalue ^«o tier Atrenif ilvr wtribliuheo G«nitiiliMi. Cerilr.-Hl, /. (lyn., 

, _r IlttmatoMiIpinx bci Gyimtresien. Ibidem, p. .1(10. Pour Veil. L'ti^mnto- 

cnmi'li'iue fr^ucRiini-nt Ik gyiiAlr6i{e, eat. coinnic outU! denti^re, buuh la 
>1 iin mCiDe nroecMUH plilcKinaai(iu« iufootieux. 
^maUHng klin. Vartraf., 1(10). 



I2S 



Sl/RGERy UF THE VAGINA 




accom|>aiiy vuU'o-vaginili.s. We should also look for and treat 
complications or secondary troubles, oiiibolisui and thrombus of 
the vagina and vulva. Think of a gonorrheal nffectioii or a hcoi- 
nrrhagic vulvo- vaginitis when iiiie is brought into conlact with one 
of these cases wrongly cited as precocious menslriiatloii. This 
is particularly the case if it occurs in a new-liorn child, etc. In 
this manner one may prevent the later development of gv'nalrosia. 

If the lesion is already present, there are two aspects of the 
case to consider. 

I. We have a simple stricture. 

3. Or there iii a complete oct>lu.4ion, i.e., atresia (avv"t\ 
the vagina. 

1. Strictures of the Vagina. 

In limited steno.sis, without a surrounding quantity of cica- 
tricial tissue, simple dilatation suffices often enough to enable the 
canal to maintain its accustomed caliber. In such a conditioa J 
we obtained camplete success by the pa.ssagp of bougies. The 
case was that of a young girl who had reteation of her uicn-^ 
struation due to union of the vaginal walls.' f 

The successive divisions of vaginal tissues, follouvd by the 
introdnction of ImiHs or cylinders, increasing gradually in size, A 
was advocated by Bozeman. " 

To-day, if we arc dealing with the cicatricial ti.ssue, generally 
we cut through and jolhic icith immediate suture, after lia\'ing 
stretched the structural with retractors. If we are dealing 
with a cicatrix of the vaginal vault, draw the cervix to the opposite 
side and cut through the tense tissues and remove as far as 
po.s«ible the fibrous tissue. Secure bleeding vessels and the 
suture the mucous membrane. 

If Ihcrc exists above the cicatrix an extensive cicatricial in 
duration, one may injure the uterine artery during the excisioi-^ 
of tliis tissue. This is not of great importance. Of muekra 
greater importance, however, is the possible injury to tlie urethr^Ei 
or the bladder. For this reason, before deciding to intervene i 
these cases, weigh well in the Iwihinee the operative risks and tl: 
inconvenienras resulting from a cicatrix. 

'Thin wiu piililinlicj l>v niw of otir |>upiU. Alinmnn. ConlritmUon h VHiie di 
rManlion ilra r^xtu. Tit. de fatit. ISSa-lsSl. Nu. 106. 



as 

i 



^ 



THEATMEXT OK TUMOIIS 



127 



When the cicntricial tissue occupies a cerbtin length of the 
[vagina, incision followed hy suture becomes impossible. It 
becomes necessary, after rciecfwn of the fibrous iis«tte, to apply 
to the raw surface grafts which one takes from |iarts where the 
vaginal mucous membrane is profuse. It may be necessary to do 
this several time:i and the patients generally get tired of it before 
the cure is complete. 

During pTeffuanry the same treatment is indiealcd. 
During labor, if the stenosis is slight, we may cut through the 
strictures that are most marked, and apply forceps. How- 
ever, the dangers of tears, hemorrhage, and of fistulas communi- 
cating between the vagina and neighboring parts is such that we 
do not hesitate to have recourse to Cesarean secti(»i. the advan- 
tages of which are to-day so well established. 

Even if the stricture is light, we folN)w the Cesarean .section 
with a subtotal hysterectomy, in order to avoid the retention of 
lochia and further pregnancies. 



2. Vaginal Atresia. 

0[jerativo indications differ according as whether the atresia 
i* complicated hy retention of tlie menses or atresia without 
retention or any other com plication. 

I. Menstrual Retention. — This condition most frequently 
"Iraws atlenlion to the malformation which is unnoticed until 
pul>erty. Cases have lieen pulilished of inijjerforate hymen in a 
luitc young child where accumulation of mucus behind the 
mcmhrune has produced a grayish tumor which l>eeomes promi- 
nent I)eiow the urethra when the child cries. 

In all cases where retention occurs l)ehind an imperforate 
^'jnien. the indication is plain: let the fluid out. 

The ojwration is the simplest and consists in a crucial inci.sion 
<rftlie most protulx-'rant |>arl of the tumor. The gitmt point is to 
l>kc all preciiutions against infection, fatal septic complications 
laving frequently been observed and esiKH-ially in tho.se cases 
where a hematosalpinx exists. Ilefore opening the relrohy- 
iDcnal effusion, disinfect very carefully llie operative field. Then 
fopiy the vagina and uterus as completely as possible of clots 
tnd liir-like blood collections they contain. Douche thor- 



128 



SURGEIiy OF THE VAGINA 



ouglily both cavities with sterilised norniHl valine and taiiipoi 
with iodoform ffiuze. 

It is as well to see the case during some months to see that 
there is no reunion. 

Wlien the retention of the menses is produced by an airvtia 
oeeurrifig high up in the vaffina, the indication is the same. Wd| 
must make a route from the cavity containing the fluid to the 
exterior. If it consists of a simple cavity the operation is easy. 
It is quite sufficient to excise the olislruction and afterward. 





V 



X'W^v:^. 



yiii. 91- — llcmnlocolpoi ftbovc a votptiiLt «;(itLim- 

reunite the walls of the Iiemorrhnjfic pocket, so to s|)eak. lo the 
inferior jwrtion of the vagina. If. however, the occlusion is Jiigh 
up. then the ojieration hcconies more complex, and one is forced 
to make an artificial vagina. fl 

In all these cases of mcnstrnni retention, wherever be the 
seat of the obstruction, one should examine into the stale of the 
tultes and see if they are the seat of a large dilatation. Itecausc 
rupture of these tubes has occurred after the rapid evacuation of 
retained fluiil. IJefore operating, even in a .Mmpio iniperforalion 
of the liynieti one sliould asciTlain liy a combination of a digital, 
rectal, and abdominal examination the presence of a me<]ian 




TREATMKXT OV Tl'MORS 



lay 



I 



^'agiiio-uterinc tuiiiur of two ur more oflt-ii one laterally [ilnced 
lumor. uhifh feels like n liematos»l[tiiix. If one ascertains the 
presence of similar turnurs, one slunild conitiiencc, and Veil is 
very insistent on this point, by opening the abdomen to see the 
state of the adnexa. The tubes an- removed wliere they are 
much chnn^d from Ihe nnrmni and if there exists a coincident 
fxlended atresia of llievaj^na. If. however, there is a hope of 
irestablishiiig thevafjiiial canal and if the tubes ore not the seat 
of irre[>arable lesions, a sal]>ingo3lomy is the usual jirucedure. 

2. ^fotimen withuiU Mnmintal Itckniwu. If Ihe uterus is 
devcIo|M'd suthcieiitly to hope for a reoslablishinent of the genitjil 
(unctions, then one slmiiUI attempt to make an artificial vagina; 




fig. M. — The aeptuin i- ;i'-i-i '-"l nmi the huIiiks nro innortcd for union. 

if. on the contrary, the uterus is al>scnt or very atn>phit'<l, it is 
^iin|)lcto have recoui-se to easlralion. 

3- AbHence of I'aytnu tciihniit ('atnplicafion.1. — One is in a 
<|ii.inilary to know if one is atithuri/ed to allow a woman to run 
opcmiive risks in onh-r to allow her 1« enjoy non-fecnndant coitus. 
In f«ct, religious arjjuments have been used against it. In prac- 
tice it U certain that if a woman bitterly laments her undeveloped 
'widition. the surgeon is authorized to makea nco-vagina in order 
'" allow her to satisfv her sexual instincts. 



3. FormatioQ of a Neo-vagina.' 

The first attempts at the formalioii of a vagina have Ijeen the 
"Milll of o[>ening a sac in cases of retained menses. Dupuytn-n, 
•n 1817, after incision of tlie perineum, pushed Ills way through 

'^W^t Dumibmcu, Conlribution >l I'^ludi' dm absi'iicrs congAnitnlcK <1ii wtpu 
'*0*lfi |M ad point He rue chlnitKical- Th. de Pari*. 189ti, Abmin Rrullieni, IW 
rMMiwljiMi of & N«w VkgiiiA Am-J.ofOhfifitii-^, Npw York. IK06. T. 11. pp. 2»»nnil 
M. (In Uieae publicntioiu will bo (ound Uie majority of publUliori ohnorratioiu.) 
I 



130 



SURGERY OF THE VAGINA 




Fio. 96. — Heppner'B Operation. An H'Shaped incisioii at the level o/ the diaphragm 
permits of tracing two flaps which clothe the ant«rior and post«rior watts of the neo- 
vagina. The lateral portiona are formed of two lateral flaps which are twitted on their 

pedicle. 




Fig. 97. — Fleming's Operation. The first flap consists of the hymen, the posterior 
portion of the labia, and part of the inlegunients of the perineum. Its base lies below 
the meatus and constitutes the anterior wall of the vagina. A second flap cut at the 
expanse of one of the labia majora, with its base anterior to the anus, forms the posterior 
portion. 



TRtATMlCXT Or TUMORS 



131 



Uic tUsuos with It blunt itistrutncnt until lie cHme into contact 
«ith Uie collection of blood, wliich he enabled to cscajje. In 
1843 Vnlkume operatwi in a similar manner. Amussat. in 1832. 
proceeded slowly to force back the tissues taking fifteen days to 
reach the nienstnial etTution. 

These procedures oj separation and ftreaaing bark of the ti»siips 
certainly produce a cavity, but the difficulty is to maintain its 
dimensions sufTicient for a iico-vagina. 

For this purpose one is forced to resort to eonUmious difota- 
tion with tani[>on!(, Guriel pessaries and wooden or glass cylin- 



•j:-^^ 



v\ 



Jh^. n. — Andcraon'a operaliun, 
T»Qflip^ ABCDond ECDfcblho 
•J* wtorm- and potMrior walh of 
■» ooo-vaclaa. lli» ktcml wiill'- 
*«oom«d witiiflKp ACQ uid BUU 
■wntil Id pnrt bjr tli« lobik minoim 
*althlHivlx«n«pHt. 



l-'ui. 9fl.— I»nac'» oporniinn. A 
oimilnr iiicUioD limit i ■ Snp. nliicli 
la ^riLiliiHlly piinheil back Ami cuiries 
toACtiuithc funclUM of llic now vu- 
^iin. Iw iuit«rior iiortinn will bo 
clothed with Tl^encli's grafta. 



'Its. The resull.s were mediocre and there was always a tcn- 
'leiHy- toward closing of Ihe caWty. 

In addition, in order to obtain the dilatation 
"•liich has just In-en formed, resort has been had 
*llli epithelium grafting. 

This has Ih-cii the j>racticc of the nmjorily of 
Ileppncr from 1872 was in the habit of making 
incuton in tlie middle of the iiitcrtabial fliaphrugm 
■Wof the two flu|>s above and below the transverse 



of the cavity, 
to clothing it 

gynecologists. 

an ir-Kha|>ed 
and he makes 

branch of the 




:.i-2 .-irRGERY OF THE VAGINA 

H in order to cover the anterior and posterior waUs of the neo- 
ru::inu. Two elliptical incisions on each side limit the flap^ 
which are twisted on their pedicles in order to clothe sides of the 
cavity isee Fij:. 961. 

^ince Heppner's first operation, numerous analogous ones 
have Iven trieil with ever\- variety of flap taken from the neigh bor- 
iti:: ^virts. such as the internal face of the labia majora and mi- 
rntr.i, irenitiwrural i^on and buttocks, etc. (Figs. 97 and 98). 

C>ther> have simply put Thiersch's grafts, rolled on a large 
m.hhkI. ou the raw surface. The sound, covered over with grafts, 
:■«« ■iurtVv exienuil. is introduced into our cavity and fixed by 
.1 ■iutut\' ..Czempin. Al»l>e. Forgues, Tuffier). Grafts from the 
laiiiit have U-en ustni \SchaIita) from the intestine of another pa- 
iiciu o(.HTat»:>l on for artificial anus (Kustner), and from the 
■iiiKvus nu'Tubrane of a rabbit (Sitsiusky), from a vaginal pro- 
:«[>>«■ ,\lrtckcnr\xll\ and from the thigh (vVbbe), etc. 




■ ^■ : \i ■uv'-t.'(i'.U'Cnuv grafw fixed, ilpnudrd Hurface extenial oa a g\aea cylindi'r 
oiiverfd with rubber, 

1*1. i ;t' v'.Mc us«'s simple grafts or has recourse to autoplastic 
V .j\*. Uio cK-atri/ation of tlic lerniinal and dihedral angle leads 
^...ot»iIl> U» the ctfaivment of the cavity. 

*■ I ^'ivtci' to prevent contraction of this dihedral angle, Isaac 

...N . ci^vular tt»p which comprises the imperforate part and 

K .\\i vi -«t"t »^**" *'»*' '*''"" "i''">ra (Fig. 99). He detaches little 

> ^ t: -v V ^vtHt*herv of this strip from the parts which surround 

ts" VN-\.i*«>if**; prx>4:ressively toward the bladder anteriorly 

vvW'\'ii> V^^a^l the rectum he gradually pushes back this 

«. .. ,».N^iN^ .'^W. vkvp<'r until it forms the terminal cul-de-sac of the 

, ^ . *,-«s ^>.i-* d»«tt'. he supports it with a glass tube closed 

., ^,,j^.; ("S^ vvie of this tiil>e is clothed with a series of 

n >■ -h '■.•ftiV \^^h"h «»H f»""iu sides of the artificial vagina 

' \Ttix m.-lh<>l *>*"■ "*** **•'*'" S"*"">' followed and the successes 



TREATMENT OF TUMORS 



las 



hnve liei^n about tho same as iit those instances where it lias been 
possible to fix the ftapx to ihr ujiprr lutriiun of the genital rannt, 
which luis been diUtttd by bluod und is still pre-sorved, or to u 
denuded cemx uteri. 

We Wlieve that in all cfisr.s of imperf oration where it is 
iiujiossible to find irnniwliately by exn mi nation of the vulvar 
ini[>erroralion any perreptible <'olle<rtiori of idood on the uterus 
itself, uri ex[ilorat<)ry' cfliotoniy should be resorted to. This 
permits of finding out Ihe state of the deeper placed organs and 
of removing the Iieniutosalpinx whieli may l>e nlxiut to burst. 
or at least of evacuating its contents and then of deciding if 
U is neeessar}' to attempt a vugino-ulerine recunstitution. It has 



v^.; 



4 "^ 



r- 



Pw, 101. — The twixlottPil lines iiulicatc Ihc roillc to 1* (iillowaj. dthcr l>v llii- pi-ri- 
ywilfoin ono dir*cUtin or x\iv nlKicimcii (rom the atlipr in urtJrr lo reach iV vajiinftl 
ludu(Viitebcrg). 

"Iw the advantage of faeilitaling tlie findinj; of the cervix uteri 
"^fiitb one a])]>roacbcs from above downward. Sometimes it is 
""Well U> strip olf the ])iTitoneum fn)m llu- anterior surface of the 
•rtfnis by the abdominal route. Then separate the uterus from 
'w hladdrr and in>en the cervical cavitv in the median line, 
Aow join the separation above uln*ady commence*! at the peri- 
•tiim and suture the lips of the open cervix or the existing 
^luil fundus to the autoplastic flaps stripped up from tlie 
Krineum (Figs. 101 and liii). 

Lwim. Kartiniinii, Tiil5<-r lOiiU. ii M/m. rfr In Sueifft rf* Vhir. dr I'arin, 1904, p. 
WI), nofmcUT. /.citurh.f grh. iin/i '•J/"- Sliitliriirt, 1004, T. I.H. p. I. tlitlbiin, Ffiui- 
MtMld, iVinjtcr. nVriliu-iin i-n Alkmftgiip, Vlnulwrg. Siniili I'l Watcrmiinii in Anicricn 
wVwl Ihe [irfliitiinun* cdititnmy. 



IM 



SURGERY OF THE VAGINA 



In cases where a small vaj^'iiial fornix full of mucus was to be 
found, Scliwiirtx' was satisfied to draw- gradually tlip li)>s of this 
little cul-de-sac downward and .suture them to the vulvar incision. 

In the absence of any vaginal fornix, if the uterus is accessible 
below, it Is possible by Polosson's plan to iraeh the cervix by the 
lower route and to fix it to what remains of the vaginal or vestib- 
ular iniicuUN nu'mbraue. The uterus tending to nsr, inulHlizes 
Utii* mucous membrane in a slow and progressive fashion, and the . 
result is much lietter than one could ever have expeclc<l.^ 

/fnvni:fif»/i><ii 0/ a Vaytna in Abtence of Vlerun, hy Ihe Supra-tymjAynal 
R(mlf.— \tt alt-irnredf thr Hupmor {Hirtiuii of the Tagioaand utrrus C. Beck* 



,^: 



u 



nu lUC). — OwniUoD K-rfninated, the v.iRJnnI fiuidiu liiu been autunsl to Mm* flk{i> 
■tn)i|W*] up from Ibe {icrliieuia (Vlneborg). 

lui< nnxmrw to tlit- high »ute. but ex trn peritoneal in order lo draw the 
l>i-riiir«l KiiifU into itic hjiiogBslHc region. B_v a Irftiisvente su)>ni-sym> 
it)iv*iul iiuHMon lir |K-iirtratcs Uir sub-jieritoiii.-'al space, pushes back the ■ 
iH'nliuiriiiii above atid Mrpuntleii the partii until he is nblc to ninke n pair of 
Itiix'riu ImLrr into the renter of the vijIvh. With the winie forceps be drawn 
till wlwivc Ibe pubis two flap! fnmi the thighs whieh he ini media te),v sutures, 
ithtM'r Iht' pubi!>. to the itulKrutancous tissues, in sueh a niauner Ibat their 
VHt«ut«m« surfNit's opiMse and their deinided surfaces con«!>]M>nd lo ll»r 

■«lflKw ppe(»areil. 

riwtMiVat/u/nw I'/ ihr InUttiiu. — Some operators have borniwe<t fmni Ibe 
Wkblw'riltK iHlestine h seguienl sufficient to eonstitule a vsgina. Snej,iiireff* 



I 



. OGl. 



* vCil. ii.»«t»* * fJr'Mlw**, HiHs. nwt. -owml KonM. T. t. p. 742. 
tQuiMI, sZmkTo^- >««■ XXVlII. p. 772, 




TREATMENT OF TUMORS 



135 



makes an incision along the left border of sacrum and coccyx, resects and 
then isolates the rectum. He cuts through this and the inferior portion 
occupies the place of the vagina; the superior portion is fixed to the place 
left free by the resection of the coccyx. Then splitting the perineum he 
looks for the upper pocket of the vagina, opens it and makes a communi- 
cation with the inferior rectal segment. 

Gcrsuny,' Fedorow,' content themselves with covering the new vagina 
with a flap denuded from the anterior rectal wall. 





Fio. 103. — A Begment o! the 
pcl?ic colon resected by the Ab- 
domen is being drawn into the 
denuded perineo-uterine portion. 



FjG, 104. — The continuity of 
the colon reestabliehed. One of 
the extremitiea of the rcBectcd 
loop is fixed to the cervix tuid the 
other is closed (Baldwin). 



B&ldwin' resects by the abdomen a segment of the pelvic colon, draws 
It down into the denuded perineo-uterine segment and then at the end of 
BtteeD days destroys, by forci pressure, the septum which separates the two 
onsches of the loop and is destined to constitute the neo-vagina (Figs. lOS 
Md 104). 

' Genuny, Wi^. med. Woch.. 1904, T. XII, p. 486. 
'Fedorow, Zmt.-Bl.f. Gyn., May 19, 1906. 
'Bildwin, Ann. of Sargery, 1904, T. LX, p. 398. 



CIIAPTKR III. 

PLASTIC OPERATIONS ON PERINEUM AND VAGINA. 

Summary.^* iencral technic of plAKlio openttiniiK. — Treutnicnt of 

(wruK'ttl li-«r*. — ^Col(»>-]>iTitHNjrr}iuiihy. —Anterior colporrliaphy, — Narrow- 

ag of the vagina hy introilucing mctallu' siituri-. — Pnrlitioiiiii)^ of the vagiiiti. 

— Colpectoiiiy. — 'Imitnu-iil of rcdo-vjipinal tistultr. 

The plastic ojioraliims pritcliscd <hi vugiiia mid j>t'riiu-um are 
numerous and procedures innumerable. All have some ]»oiiits 
in ct>iiimoii wliicli we will dcscrilie before tndivichiali/ing. 



1. General Technic of Plastic Operations. 

I. Before the Operation. — liefoiv eaeh ojM'rKtion einply the 
intestine, partieuhirly in case of inserlinff penneaj sutures, as the 
evaeuiition of old s(Tl)ii]oii.s nuisse.s may lead to tearing of the 
sutures. Purge the patient the niglil before the operation and on 
the morrow give an evacuant enema. 'I'he preliminary evacua- 
tion is followed by sliaving of the vulva, vaginal injections an<l a 
thorough bathing with soap iind hot vater. 'Phis constitutes 
the haltilujil j>rc-opcrative treatment. 

There are cases where this pre-operative treatment should be 
longer. For example, wlien there i.s a complete prolapse of tlic 
Uterus with much edema an<l ulceration of the vagina and cervix 
we find it neeessary before operating to touch up the ulcerated 
areas with silver nitrate to reduce the prolapse, to lanipon the 
vagina with iodofonn gauze, and only operate when the cure is 
completed. 

•i. During the Operation. — The patient is placed in the dorso- 
sacral [K)sition and drawn to the edge of the table, her gown 
pushed well up, the thiglis and knees flexciJ and enveloped in flan- 
nel stockings and tlie feet fixed as in Fig. ttlf. 

The vagina, vulva and the .skin of neighboring regioas are 
disinfected liy the u-sual methods. The o|)erative field Is limited 

1.10 




GENBRAL TECHNIC OK PLASTIC OPERATIONS 



137 






owever Iiirfri* thi' fif!<I |)ri*|miv<l). a cfiilnil s|mco showiiif^ fur 
the vuh-n aiul perineum -surrounded hy sterilized compresses 
^%'liich arc lu-ld topt'ther liy small fnixvjw. 

An assistant looks nTter the anesthesia: two others, placed to 

tlir Hf^ht anil left of the patient, assist the sui'g«>tin who is stMileil 

iM'tween tlie patient's le^^s. A tahle funiished with his instru- 

iiirnls is on Iiis right haiul. An imjxjrlant ]>oint is to keep 

Ihe |>arls tense to which the bistoury is applied. To do this, 

draw on the neighlmring pnrls with Museiix's little forceps or 

ni.iv Ih' with tenacula; these serve at the sinne time to fix Uie 

* 

limits of the surface about to Ite strijjpeil oil'. 

In the course of the operation it is necessary to avoid lowering 
the vitality of ]Mii'ts which are to be united either mechanically 
[pulling on. ei>n(iision. cutting tof> thin grafts) or <-hemica)ly with 
loo strong antiseptics on rawed surfaces, 'J'o this end. avoid con- 
tact with tampons, antl to get rid of blood irrigate with sterile 
water, saline of 7 to 1(H)0, and at a temperature of about 38° C. 

In nnler to put in sutures, don't wait until the denuded 



:^ 



Fio. 105, — P*Mer'» xmiiul. 

Sltufes have drie<l up, but place fine catgut sutures on any ves- 
•*!» of importance. 

Ojienite rapidly co%'ering completely the raw surfaces and 
Ifave no virtual cavitv where blood s«tiiiii m»v collect. 

.U suture material, use catgut for buried sutures, even for 
uose placed in the interior of the vagina, in order to avoid .^epa- 
liling parts recently united in order to search for deej> sutures. 
Tie non-alisorbjible sutures, silkworm gut, silver %vire. bronze 
*luiniiiiuni. do well as perineal sutures and for thijsi' pla«*d at tlie 
Win- of Ihe vulva. 

The dressing consists in the intro<luctioii of an iodoform jthig 
wto the vagina, the external portion lieing jircssed back on the 
Knncuni and so leaving the urinary nieiitiis fit-e. An antiseptic 
ur^wing is then placc<l on the vulva externallyand niaiiilaiucd with 
3 teri'iclle disposal lik<- a pair of bathing Inmks. 

8. After the Operation. -During the firel few days, in tlie 
CMe of operations about the vulvar orifice, it is Itest not to let the 



138 



PLASTIC OPEHATI0N8 ON PEajKEUM AXD VAGINA 



patients urinate, Imt to do an nseptic catheteri^Jition of the 
bladder witli Pezzor's sound. TIu- food sitould !«• rcducwl during 
the first few days and a dose of castor-oU and an enema should be 
given on tlie inorninfj; of the third or fourth (i:iy. We do not 
advise proloaijed daily K'^''"J^ '*f opium. 'I'luit results in hard 
accuinulations in the ret-tum very difficult to get rid of. After 
the third or fourth diiv, \vc move the bowels diiilv. 

On the eighth or tenth day we remove the non-nbsorbnble 
sutures, earefully washing the parts, being <'an'ful to avoid pres- 
sure on the lines of sutures with the cannula wlien the dressing is 
removed. 

The patient is confined to bed 15 to 31 days and abstains 
from sexual congress for ten weeks. 

i. Treatment of Perineal Tears. 

The treatment of perineal tears should be preventive and 
curative. 

Preventive Treatment. — If the terminal part of labor is 
observed, at a given moment it will Ik- noticed that the perineum 
which up to now only bulged during a pain remains distended 
after the conlraetion, and the head which appeared almost entirely 
eiivehtjted does not go back after the pain. If ai lliis moment 
the accouchement is allowed to proceed, the head by a l)rusque 
deflexion, resting with its forehead on the fourchette nnd peri- 
neum, tears them lioth. It is the brow which causes the perineum 
to bulge, Ijecause it is the i)art the furthest removed from the 
neck and corresponds to the greatest diameter of the head, 

Ancient accoucheurs sought to arrest the exjnil.sion of the 
head in order to give time for the orifice to extend. This is easy 
with forceps wliich grasp and firmly retain the head but impossible 
in the ordinary a<*c'ouclienient, and the perineum will tear under 
the hand supjiorting it. \'arnier teaclies that one should prevent 
the forehead appearing before the parietal eminences and neck 
are delivered. 

To do this press with the riglit thumb in the bregma which 
has just appeared, Miid tlius stop the movement of deflexion. With 
the thumb and index-finger of the left band, he makes the right 
and left labia glide over the eorrcsiionding parietal eminences 
(Fig. 107). Il is only wlien all tlie parts have appeared externally 



J 




OF PERINEAL TEARS 



jrogressiveh the deflexion to occur, 
h, mouth and chin to appear succes- 
I; there is no fear of perineal tear. 

vulva are useless and only lead to 

is feared, make an oblique incision 

Fk median section increased by the pas- 




139 



Fig. 108.— Sraellie. 
ar at the period of expulsion. The fetal hetid engageB in the 
iarence. The end ol the fifth |)i?riod is near ana if it ia 
flexion the aommiBsure will buJge forward and the perineum 

head risks the rupture of the muscular tissue of 

innent. — In spile of all prevention the perineum 
rupture is lateral always, the posterior column 
na, fibrous and resistant, remaining intact. The 
I and vulvar constrictor being torn through, on 
hem we get a lozenge-shaped wound which, left to 
Irize, results in a perineum which no longer plays its 
iporting agent. 

efore highly necessary that the ruptures are attended 
■ as possible, taking care not to limit the suture to the 
would create a perineum without any solidity, 
te Perineorrhaphy. — This is more or less simple 
i the rupture is incomplete or complete regarding the 

Pratique de$ accoiichemeril, Paris, G. Steinheil, 1900, p. 99. 
Diviiion of the Vulvo-vaglnal TiHsues. 



I 



ox PERINKUM AND VAGINA 

tit tfanr two enses, tlo not h(>sil]itp to ]>rn<-e4>(I witli- 

bttt comfort the patient with encouraging words. 

M» i mtmm p teie rupture the opci-iition is very simple. 

:iii!»t<J«uia«U the {>arts. place an iodoform tnnipon again^it 

■ > arrest Uet^ing and hide the wound. Separate the 

iwwv '-Mouneacu^ from above down, place .several ciitgiit 



l^\ 



% 



Fio. Iir. — Monns of prpvnnlinH tli" pcrinwii nipliiro (Varaier). 
\t l)>* lauiiirnt when i\\v ivrvhvoA siuiruaclK-B the voinuuvaiirL- dintooded to its ntaxt- 
■ninm. ll>c Uiuiub »to|>n tJic [ii-fli-xion. Iiic delivery lend of &fth poKod) tw^Lnx, not by 
i^i'tMJnn of ttie forehead, hut by the Ktfv»t of tho perineum. 

sutvir*'-'* in the vaginal tear, This tear often goes Ingher tlian one 
would think nfter a siniple cxtem;d inspection of it. Then suture 
llie iR-rineai ru|»Lurc \\ilh .silkworm gut taking care to include the 
extreniilie-S of the torn vulvar con.slrictor and getting good con- 
tinuity along the length of the wound and leave no virtual cavity. 
One or two su|jerficial sutures complete the operation if the tear 
15 cutaneous. A.s a <li'essing, iodoform powder ;ind swjih of the 
hvdrophile cotton which should l)e fre(|ucntly removed during the 
li'nil few davs. On the eighth or the tenth day, remove sutures, 
and if no infection, cure is complete. 

In Ihe complete rupture the operation is more complex. Il 



TREATMENT OF PERINEAL TEARS 



141 



bfirst nwessarv to cI<ksc the iTt-tal .side hi order to transform the 
coiiijtU'te tear into an incomplete one. This is done hy passing 
H serie.s of catgut sutures wlucli iippose the lips of tlu" recta] 
tear and are applied from the side of rectum. These cat}(uta are 
surces-sively place<) from ahove down, the most inferior compris- 
ing the sphincter iiliei's. Then the vaginal tear as in incomplete 
ruptures is done with catgut and the eiitJineous with silkworm 
ful, the mast inferior .stitches taking in the extremities of the 
sphincter which is a|>]>ro\imated as well as possible. 

.\fler two days, give a laxative and if nwes.sary an enema, 
dineting the ciinnnia toward the .sacrum and injecting theliijuid 
wn- gently, .\fter this a daily motion is indicated. 

With a eeniraf rupture uf the perimitm. llic hest thing to do is 
lo cut across the |)erincid Kridge lietween the ni|>ture and the 
fourehette. Then the corulitions are tlio.se of an onlinary j>erineal 
tear which is treated as before described. 

The.se immediate [KTincorrhapliies an- put off ffir.some days if 
die patient is c.\haust(Ml with a long ]a)>or. an abundant liemor- 
rliage. or witli attacks of cclanijisia. .\gain, if tliere are very 
("xlensive local injuries or violent contusions due to prolonged 
liancuvers, in such caiiea we do what is calletl in France the 
"^tMuchtr)' immediate |M>rineorrhap!iy' which has only one contra- 
indication, viz.. pnerj>cnd infection. 

.■VflersulH.-ut«neous injection of cocain, curette the wtmnd and 
'*(ilurc OS in immediate perineorrhaphy. 

Secondary Perineorrhaphy. — .Vfter the fiflcentli day it is impos- 

sil(U'. a.s the immediate .secondary perineorrhaphy as n part of the 

*eor will lie already <H)vered with cicatricial tissue, ^'erneuii ad- 

■ visM rawing willi a thermo-cnutery, suturing the [larts after 

H^{Miration of the scars. This is not to be recommended. Better 

^*ait some weeks until the tissues assume a definite appearance. 

U»en carry out the late perineorrhaphy. Operate six weeks after 

the accouchement in women who give the breast, and after the 

first menstruation in others. 

Late Perineorrhaphy. — ^This is practised several months after 
'■»\ iicc<iiiclieiuent. We will describe it later under head of Colpo- 
pi-rineorrbaphy. 

'TcIUm. D« U pjrin^urrttptiit! iiuiDi(ili&lo Mconduire. Lgon midiatt, IMS, T. 
••XXvill. 



I 



112 I'LASTIC OPEHATIONS OS PICRIXKUM AND VAGINA 

3. Colpo -perineorrhaphy. 

Old procrdurcs, .siidi as Kmniet's, which aimed at replacing 
tho perineum, have fifiven place, even in cases of a simph- tear 
without prolapse, to colpo-perineorrhaph.e.s. Truly, in a simple 
perineal tear there is also a (ear of the vagina and enlargement of 
its orifice and thus aij operation to be complete should reconsti- 
tute vulva ami perineum and constriet the enlarged inferior 
vaginal portion. 

A good reconstitulion nearly appnwiehes the oj>eration for 
prolajjse. In both cases a colpo-perineorrhaphy is done. There 
are in oi>erating great differences according to the case and it is 
cvitleiit tluit generally speaking one will ii<it operate in the same 
fashion for the accidental tear of a liealtliy perineum as for the 
failing away entirely of all the perineal .support with prolapse of 
the organs. 

In tears due to injury, then; are eornplele and incomplete 
ruptures. We will deal with the treatment of incomplete and 
then complete pn)la[»,se. 

The procedures employed are numerous and may l>e divided 
into two great categories. 

1. 0|)erations by denudation. 

a. Operation-^ by splitting. 

A. Colpo-perineorrhaphy by Resecdon. 

The posterior column of the vagina being rich in fibrous 
tissue is very resistant and Martin advises to preserve it to serve 
as a support for the new posterior vaginal wall and only excising 
the vaginal mucous membrane laterally. 'I'lns realizes Kmmet's 
new procedure which is tiniversally employed in America and 
well described in the works of Italdy and Kelly. The operation 
presents modifications according to tlie injury one is treating. 

We will describe successively: 

1. Treatment of inctHnpIctc old tears of the perineum. 

2. Treatment of comp.ete old tears of the jierineum. 

3. Treatment of ulerine prolapse. 

1. Old Incomplete Perineal Tears. FirH Stage. Fir the 
Lirniis of tiie Ucnudatum. — These hmits are variable following 




144 



PUiSmC OPERATIftNS OX rERIXEl-JI AXD VAGINA 



the dcjjrof of relaxation and increased breadth of tlie 
following on the [»erineal tear. To fix llicm. place on eacli s 
at the level of what remains of the hymen two lenacula. . 
tween them leave a pnrlion of the anterior vaginal wall ab 
e<|iml to that of the enlri' of a vagina in a virgin. A thinl lena 
lum \i (ixed on the posterior vaginal column. 

In drawing on these three tenarula. two gnmvc^ are crea 



I'ki. 100.—Plii«iug tbi^ first lulurK, mi* tim* th* (U-nndalion ivriQinntml. (JC«ffj 

on each side of the middle line posloriorly, which extend mon 
less deeply into the vagina. On the <li.stal extremity of th< 
place u tcnaculnm fonvps wliicli may Ik* ^ or 4 cm. ( 
inch to 1 \;''i inches) from the vaginal entry, it i.s tlion St 
cient to unite by rectilinear iiiei.sions the Hvc points fixed by 
tenacula to produce the rerjiiired denudation.' 

With a bistoury trace nn incision going from each aide 



* W« IUM> Ikliiitnus's ■mull foiorpv iniitMul o( tMiaeuU. 



I 





oilc willi a V'-sliapei] incision. Ihr tuti tenaculn implanted on 
lelcTcl of caruncuics (akinj; can- that the incision passes through 
e mucous membrane and *loes nol impinge on thi- skin. 
Second Slatjt;. Denudutum of Ihf Surfaces. — In order to do the 




fn. UO,-«p])i«j(if[ tbcmtureiion tbi- triAogle nxidcrvil aoui.'-ssiblc- l>y clraniiiKOU Uwflnb 

point n1 Miliirr. 

licnufJatiorr, stretch with the ai<I of the tenaeuia, successively, the 
lurfacM from the right side and left side and then excise tlie vagi- 
11^ ruucuus membrane with a hislimrk' or Kmmet's curved scis- 
ton. In the h»tter ease, the mucous membrane is raised in 
Ibr form of lillle tongues. It is very exceptional to have to tie 
iWwding vessel as a temporary foreipressure suffices. 

Third Statje. — An assistant separating the right and left 
ibia with tenaeuia. the surgeon, a little lirlow the middle of the 




146 



PLASTIC OPERATIONS ON PERIXEUM ASD VAGINA 



triangle of denudaLion. insprLs his first silkwonn-^ut slitcli. By 
drawing downward on this stitt-ti Iieid between the medius and 
ritij^-fiiij^or. In- draws into view tin- superior jKirlion of the denuded 
triangle. He brings into apposition its borders with catguts 
|>assed on a stronj;Iy curved needle. Tie carries on the same pro- 
cedure from the other side. 

There remains now a wound only moderately deep, formed 




Fid. 111. — Th« vaginal suUires have be«n iDBerted. The pcriaeftl oneo ar« iiuwrtcd bul- 



by the reunion of the vulvar )>ortion of the lateral triangles and 
of the CH'iilral portion of Ihe denudation. Two silkworm guts, 
one passing by the su])erior angle of denudation and through the 
posterior median eolumn and another uniting the skin below, 
suffice to terminate Ihe suture. One or two extra catguts between 
the cutaneous and vaginal sutures, and some superficial silk- 
worm-gut sutures unite ihe skin. 



COIJ'O-PKniNHORmiAi'llY 



147 





Fta. 112— nietndngor thn 
denudalion. 



Via. 113. — InEcrtion of thtt auturw. 




It*. — VMuoonfanpb)' lij- i-oinplcii- .irni^imipin m ijip pvriiicuiu i*denil(t«tian wul 

inKcrlkin o( sulurea). 



148 PIJISTIC OPERATJONS OK PKRISEUM AND VAGINA 

Veifs Procedure.^llp oiH-mle.* in rnth«r a Kprdal mmiiirr. IVps 
frum the princijile timl the jicrincal tear Is mosl oflrn uailatoral. he m 
« circrtilur inci»ioii. abc. nl the junction of mucous iiiritil>ritnc and i 
H« i-xciscs a |>aranicdian triangle, ale, disncrti u(> the flap abd. and 
uuilc.t Uk [totiitK ned ^nliicli [itiiiit.t owing tn Ihr tliuMTlion i>f the fUt 
longer indicate an angular line) to dc. Then he brings together ab an> 

Thin procedure is asj-muetrieal like the tear: iheorelieMlly it woul 




Fia. 1 15. — PBrinMrrhkpby in tamplai* niptuiv «( the pc-rinnun (operation tcrmin 

prcfenblc t<> others, as Veit says, liccansc it i& the only one wbicli t 
into account the anatuiuy of tlic rupture. 

2. Old and Complete Tears of the Perinetun. — Before ope 
iiig some g}'uecoU>gi.sts advi-si- tlK> dilnljition of the s|))itncte 
much as pos-sible in order to elonf^atc it and pit^vcnt spasm 
coiitraclioiis which may supervene during the first few days 
lowing the suture. 




fKEORilHAPIIY 



149 



I 



An incision is iiuuU' over tlie rccto-vuginal st'ptum about 1 cm. 
alKtve the line of junction of the rectjil iiiul vajiiiuil imicous ineni- 
liranfs. This line curved backward jilniosl Ui llic level of Uie 
cxLremities of the torn sphincter. This incision constitutes 
the posterior portion of the deiuidiition, the anterior \x>r- 
tion of which is identical with that which wc have described under 
the treatment of incomplete ruptures of the perineum. 

Inserting tlie index finger into the rectum, the surgeon dis- 
sects the little band of recto-vaginal septum which has remained 
intact, in such a manner as to fn^c it and to ]>ress it clow n below 
like an apron over the orifice of the rectum. A close dissection 
enables us lo find without perforating Ihc intestine, the two eiuls 

bof the torn sphincter and of freeing them to the extent of about 
11/2 cm. It suffices then to freshen the end.s which are covered 
with ciealricial tissue to bring them in apposition and then unite 
them with catgut sutures. A few catguts inserted In figure-of-8 
form unite the deep parts in ihc center of the wound in such a 

» manner as to avoid any cavity. 
Ilien do the suture of the [lerhicurn and vaginal mucous 
membrane as in incomplete rupture. The operation is termi- 
nated bythesutureof the [M)sterior flap which is like an apron and 
■ which hangs more or less folded over the anus. In keeping these 
last sutures long and making a light traction on them, one can 
draw tJic whole suture out and fix the ends of the sutures on 
Ihe buttock with adhesive plaster (Fig. 115). 

3. Old Tears Complicated by Prolapse.— In prolapse there is 

as in the incomplete perineal tear, a gaping of the vulva and 

! insiifTipieney of tjie perineal body. There is also an excess of 

I vaginal wall. The o|)eration ought to have a triple object: to 
diminish the i>oslerior vaginal wall and the vidva, and reconsti- 
tute the perineum. 
Tliis can be done by doing an operation identical to that one 
which we have described for the trcatuu-iit of incomplete perineal 
tear, taking care that we give to the lateral triangles of denuda- 
tion of the vagina considerable dimensions in length and breadth. 
so ns to resect a large urea of vaginal mucous memlirane. 
Dissect up almost entirely the lateral wall of llie vagina. 
the external border of the triangle of denudation being parallel, 
and immediately subjacent to the angle which separates the 




"-i^riC PERATIOXS ON PERIXEUM AND VAGINA 

. ir;-M.>r vau irvm. -Jie lateral. The operation becomes then a 

ir^L'te ■liiitenu coiporrfaaphy combined with a perineorrhaphy. 

■t liiiv I '■ax :issues and the presence of a rounded tumor, 

•lUAucui Lmertorir. in place of the posterior column of the 

^.lix, —imer 'his the easiest of operations. 

i^C^'^ P^QCMttie. — The denudation h&s a triaDgular form. Dimen- 

,.- ti' »t.v«fuimc'o the d^ree of prolapse. Id slight cases it is sufficient 

. tuiic ,1 .mnx.'^ la^'ia)^ 6 to 7 cm. breadth of base and a height of 7 cm. 

— - .uH^w -> erv '^'ctensire. the base mav measure 8 cm. and the height 




-. *n*»-> .■>i'**'T*"'**""''*P''y (denudation and inBertion of stitoheo). 

*v* Jl* jswt at the level of which wili be situated the superior 

^ •v'<uf<i. i* is !«««' ""'"'^ * ^™*" Museux forceps and drawn fo^ 

" " -•»?«- TV (Hwterior wall of the vagina appears directly in the 

^^.j^sftHirothfrlittleforcepsservetostretchtheflaplaterallT. 

** . ^^Tk-***'^*'*'**"*'"^"'***^*'""^^*"*^''*^"^^' Tl»«'^«''udation 

^^^ ,j^ l^stiwin'. the point of which is always directed toward 

,,,^. -Vs-io*** »^ 1^ "■!' ™"*^ according to the state of the tissues. 

*• **" ^ ^.^ Miltimeteis thick is enough. But when the wall is hyper- 

'"'"*^' ; f,«nteil »/ «nlv slightly vascular or cicatricial tissues, one 

'^"' 'tiw Jcoi^Uti**!* is complete the operator should make even the 
^*^^, »xmml and f*»' **>" purpose *»« should make the bleeding sur- 



COLPO-PEKINEORRHAPIIY 



151 



^l>ulge witli tiis fiitgvr in tlie rectum. If there nrc any little spoU not 
laded, remove them. The larger vessels are ligattire*! with catgut. 
The vigitml suturcii are uf catj^ut mid the [lerineul i>r silver. 



B. Colpo-perineorrhftphy b7 Division and Splitting. 

Langenbeck, Wilms, Slaude. liischoff were among the first 
to have recoiirsL' to the splitting of tlii' [leritieuin, hut these com- 
plex methods were not inWting; and Law.son Tait was the first 
to do a simph" and rajiid splitting. 

The procedure consists essentially in a splitting of the peri- 
neum and recto-vaginal septum by a transverse incision and in 
reuaion by following a sagittal line, antero-posteriorly, of the 
denudation thus created. The wound reunited is perpendicular 
to the incision and the ]>erincum is reconstituted between the 
nilrar orifice and anus. 

1. Incomplete Perineal Tears. — I^ Tait. with two fingers in 
thf anus, stretched the t'ourchetle transversely and divided with 
special sci.ssors, pointed and curved, the recto-vaginal septum, 
stripping the right and left sides over a length of 3,5 to 4 cm. with 
» depth of 2 to 8 cm. From the extremities of the transverse inci- 
sion he made two others, which extended vertically U])ward on 
tht labium majora. Drawing upward the fiap thus cut. he 
trani«fornied the transverse wound into a longitudinal one 
*hich he reunited by silver wires passed from left to right, which 
look in all llie raweti parts but not the skin. This he did in 
order to avoid the pain which these wires cause by pressure. 

To this operation we i)refer tlie following which in its main 
fines recalls that of Doleris' col po-jH-'ri neoplasty. 

Tlie eur%'ed incision, with concavity above, is made at the 
union of skin and mucous inenibrane. Two fine Museux's 
™tep8 mark the limits already determined and scr^"c at the same 
tune to stretch the parts. These are given to two assistants who 
draw on them and the operut*)r incises gently the middle part 
in 8 curve of about 3 cm. 'i"he surgeon goes deeper and deeper 
iwlil he gels |tasl the non separable fibrous zone which lies iin- 
BWdiately below the skin, keeping close to the vagina in order not 
to risk injuring the rectum. He then presses l>ack with his 
finger the tissues which deeply close the vagina. Follow tlie 




m 



IhLNEORRHAPHY 153 



nikw. 



until the denudation is considered 

^Ir^ Hw jve. Take a j>air of straight scissors 

^^''•' % as possible in the lateral portion of 

I one cut go through the skin and 
t to the right and to the left until the 
:^IM(i^ -ps is reached. Then with his finger 

ludation of the vagina. 
• "MMi|f Hi0 iM0 u of a dihedral angle with base below 

"t M0 ItM^ ^«i*w inal valve and below by a rectal valve. 

'•* **»■ %tf s^ - which mark the lateral limits of the 

I to the mid-point of these valves in 
l«jt '^ ^ the vaginal valve upward and the rec- 

ihe wound tlie appearance of a lozenge 
;d. Now insert sutures; three metal 
mainium) suffice generally. The pos- 





N'ecdle for perincorrhii|iliy. 

■,'li the skin of the perineum in the pos- 
ige about a centimeter from the edge of 
i then traverses the substance of the 
;>per end, care being taken not to per- 
■ oines out opposite the point of entry. 
I'.s pass anteriorly to the one described, 
i' the summit of the cleft and the third in 
Inal valve. 

liich pass easily on Kmmet's needle draw 
u-dian line. It is thus necessary to pass 
:is possible in the substance of the peri- 
ito the rectal and vaginal valves. 
■J, finished the result is not esthetic. 
Miius is a ijerineuin sufficiently thick, but 
vaginal mucous membrane forms a sort 
jinijeets over the line of .sutures. It is 



(X)LPO-Pi:RINE(>RnilAl'HV 



155 



^unnecessan' to vony about this as this mucous niembnine will 

gradually contract. 

' Wr (■(>nKi<l<rr it wtolr^K In ititavp nfT dotte to the reilunilant inuoouM mcni- 
I' fcrine pcrinctim of (he poiterior va^innl wnll and In inukc a onn-f ul suture of 
itke t^itginal flup tr> lln- ciit»iii-i>iis 1i|>. 

•i. Complete Tear of the Perineum. — In complete (lerineal 
tejir wcsliouM draw forward the Iwocxtrcmitiesof the torn sphinc- 
ter into the median line. The inciHion .should he modified and 
|bW the form of an H. 



,_J, — rcrinforrhnphy inciaion by ■putting in 
1^ la Uie slijn cut be wcu th« liiilc <l«|>rvH»ions i 
••otn t|>liin«(cT. 



ni|ilurrB of tli* 0"** 
hiii; iti the cxtKimUea 



' * o the orighml incision for incomplete ruptures, add two 
^isions which run backward to the level of the torn sphincter 
P***ted by a Hlllc cutaneous depression. 

^ lie splitting and tlie insertion of stitches presents no pcculiai^ 

f^ a« everj'lhing is done as in incomplete rupture. 

^me gyoeculofpst;) commencr liy uniting the two lips of the rectal 





156 



I'l-VSTIC OPERATIONS OX P1vRIXEV:M AND VAOINA 



\«tir by poinU of fmriod ciitgiit in^tcrtffd like f-piiilifrl's ■«iiliir<-s in i(itrii]KTi- 
touval wounds of the intcsliin-. Tlicy nrc called aJtiT Laiienstcin and only 
dilTcr from Lcmbert'.t .tiilure-i in that they arc pliu-rd on intPKlinC!* deciiided 
of iht'ir serous ooverin;;. Aiialo|;ous slltchrs arc inserted in the vaginal tear. 
Finish the operation Vjv a perineal suttire of silver wire. 

Wiitkins' hiis recently advised an operation for complete rupture of the 
perineum which Heems to him to have the folliiuinf; iidvatilaj^jt: 

1. Till- Hutures «rc away from the anus, hence infe<iion h diminished. 

i. There is no lightening' of xkin or dcalriciiil tissue nhoul the uniif. 

9, The sphincter Is sutured apart. 



n 



i 



I 



I' I.. 121 



Flo. IK. 



4. There is no danger of recto-vaginal liiitula. 

5. The post -ope rat JVC pain* are nnnimnl. 

«. Knemas may be given witliout fear t>f infection. .^^J 

The operation ik done in the foHowing manner: ^HH 

1. A tran.ivcrvie vaginal incision of a thumb's length ami a half thumb's 
hrcaillh is iiiuile above the iiiosl elevalei] portion of tlic rectal tear. The 
higher the incision, the greater is the accurily against infection. When the 
rectal tear is not extensive, the incision ought to he made at least a thumb's 
breadtli above the edge of the tear, 

2. With a pair of pointed scissors denude from i-a<:h side the vaginal 
mucoiiH membrane until we reach a jioint eorres[>onding to the extn'uiily of 
the torn sphincter indicated by a depression in the skin iFlg. 121 ). The same 



' Surgtry, Gf/neayloffy and Obtl«tric». July. 1908. 



158 PI-AS'rrC OPEItATlONS ON PERINKUM AND VAGINA 

maneuver U repeated on each side. The liailis of th« M;is.sors are separated 
in sucli a manner as to xepanite the ti!»ucs vvr}' thoroughly. 

3. The tissue lying between the two canal.i pniihiwHl !>)■ the scissors i- 
gciitty dissected nntl the finder explores to see that no uncut bands reiuaii. 
(Fig. 1S4). It U very important to dissert tiinroiiglily the deep surface of the 
rectal luucous menibmne, sn tliut when the extremities of the anal sphincter 
ue sutured, the .iphinclcr will lie only on this nxK-'ius membrane, with the 
result that tension of the sutures will be greatly diminished. 

4. The extreniitieii of the sphincter are then seized on each side with 
pressure forceps (Fig- 183). Draw out nearly the whole of the muscle. If 
the fint hold is iiLtuflicicnt, make a .-teennd willi another forceps and. if 
neceuary, a third. 

5. The two extremities of th»> muscle arc sutured with ehromicized cat- 
gut which arc passed two or three times through llic tnuseic before tying 
(Fig. 124). Include surrounding tissue with tin? muscular to avoid cutting 
through on contraction of the muscle. 

6. Terminate with llegar'.-' colpctrrhaphy (Figs. US and ISG). 

In Fig. 136 the sutures are removed from the anal orifice an<) are all in 
the Tagina. In reetnl digital exauiinalion it is easy to ascertain a normal 
muscular resistance and not the least retraction from the skin. 

The operation consists, in shnrl. in a trnnsplantation of li&sucs. The 
mucous uiembrauc, between the incision and rectal tear, is luade to form the 
external face of the perineal body. 

3. Old Tears Complicated by Prolapse.^In old tears wimpli- 
cated by prolopsc, the uijeraticm is little different. The vagina 
has suffered a considerable increase in size and tlic perineal 
support has iiuire <tr less di.sa[ipcared. We should therefore 
resect a portion of the vagina and make a new perineal support. 

The inprea.s(tl si/^ of the vagina may be corrected by any of the 
anterior colporrliaphy procedures which we will describe later. 
If. however, wc find a well-marked reclocele after splitting tin- 
tissues in the usual way. il is exlreinely easy to resect a more or 
less extensive area on the posterior vagin:il wnll and tlien to suture 
with catgut the two edges of the excised vagina. The operative 
treatment of vaginnl proUipse presents one peciiHar point; in place 
of limiting our splitting to tlie site of the old tear, we should ex- 
lend as liigh as the level of tlie cervix uteri, and this is the 
only means of reconstituting a «olid parincal IxhIij. 

The suture inserted Jn the soft parts as formerly described 
is here insufficient. We mu.st not only go deeply but some dis- 




^^^^^^^H COLPU-l-F.RINEOItiniAI'HV ISO 


* 


^^P^P^n ^^^^^^ 






^mH^' 






-^ .^^w^ \\ m \ 






f M^^K ■ H ^^^ 








J 


■ 


^^^^H^^^^pP^ J ■ 




^^■^^ 1 




l!^)ii '^ 


1 






J 


ht.1 


Xi, — Oa tbc poslcrinr viilvr ri'hiiliiiiu fniiii the ikjiliiTiiij; arc lo t>e mmi tli< 

titc k-vuloni. 


4 


4 




PlO. 138.— SutiiTc of ilw levator*. (Tli« iHMl«ri»r autiire is lied Ixil ili* uUwrn an mi^ 

iniiericij.) 



.1 



162 



PIA8TIC OPERATIOXS OS i'ERlXEUM AXD VAGINA 



tance latentlly in order to bring between the vagina and rectum 
more solid and rcsistanl tissues. Tlu-se tissues sre prinfiiwdly 
to be found about the level of the levators, and the sutun- was 
advised in 1897 by C. Noble' in Anieriea, by Ziegenspeck" in 
(Jennany, but strietly was first practised in Franco by Duval and 
I'roust' and my colleague, Pierre Oelbet.^ We have used it for 
nijiny years. 

In the case of prolapse, we must search some distance away 
for tliest! muscles toward the lateral limits of the denudations. 
They are often hard to recognize, but on feelinji with the fingers 
the bands which form the edges of Ihe jirescrved portion of these 
muscles, descending from the superior portion of the perineum 
backward from the posterior border of the uro-genital diaphragm 
to tlie lateral portion of tlie rectum. They should be freed and 
then, guiding one's nee<lle with the finger, they should be freelv 
sutured with eliromicized catgut very sliglitly resnrlM-nt. Three 
or four stitches are placed froiii behind forward and then tie<I. 

When a uniscnlar ]>erinea! body is tlius reconstituted, the 
skin and suljjacent parts are sutured with non-resorbent stitches; 
they pass through nmseh's already sutured in su<'h a manner as to 
avoid the persistence of a virtual cavity between tlie two rows of 
sutures and thus prevent serum eollcetion. 

In proceeding thus, we obtain resistant perinei and durable 
cures. 

In eases where the excess of vaginal wall seems to indicate the 
resection of a portion of it, it is extremely difficult to do it. It will 
Ije found sufficient t{> remove a comer of this wall and then suture 
the borders of this vaginal section before proceeding to Ihe [H^ri- 
neal reunion (l*"ig. H9). 



4. Anterior Colporrhaphy. 

Tiie (>i)enitive technic of anterior colporrhaphy varies with th< 
object of this operation. In the great majority of cases it is 

' Ctiarleii P. Noble. A Cont rlbuti«D lo (he Trchnic for the Cure of LaoerAlioos of ' 
PdWc Floor in Woniea. A mw. (iyn. arui Obtut. Journal. Now york, 1897, T. X, p. 412 

» Ziegoospppk, Cenn.-BLJ. Gyn... l.ci|i«iR, 1809. p. 1251. 

' P. Duviil uikI It- Proust, Technique do la tniture Ann mucclpH rplovouT)' lie I'anuH all 
ODUr* dn la pf riQ^rniphio. Fretse mfdicaU, Paris, November '22, 1W2. p. 1120. 

• Pierre Dolbot, Pirini'orniphip par inlcrponition. Bull, tl .Vfm. de la Sac. de Chir,, 
1903, p. 1003, 



Jone for an anterior rolpoa-k- willi conconiilant cystot'ek'. 
[oliowiiijr is the o]K'ralivt* prafwliin*: 

Extensive Anterior Colporrhaphy for Colpo-cystocele.— Com- 
nieiiLv l>y exposing iiiii) flrawing on lIil- uiik-rior vagiiiiil witll hy 
traclion forcejMi. A pnir of force[)S is placed on the anterior lip 



ANTKitlllR COU-OBHIIAPHY 



163 



Tl.e 




Flo. 130. — U«DUti«l Rurfftco in nntfrior colpi)rrh»pliy. 

<rf the cervix, which is drawn down and I>ack toward the four- 
*ktl(e; Willi o seeond forcc]>s, median like the first, one seizes the 
'■pnal inneou.s meuihrane immediately l>elow the urethral mea- 
tas- Filially, two forceps .syinmetrieally placet! fix the lateral 
*'«piwl wall at equal <listaiiee fn»ni the upper and lower forceps. 






FiO. 131.— TlecontinuouasutUKi-iimnieiiiiMiioiir Itic Mrvix. Htgotion'H nreilW' 

wall is II tillle deliciite Ix'cause the v«ginHl mucous membrat 
bound to IIh- (|(T]iit filtrous tissue. Hut wlieii oiio rfiiclii-.f 
vcsifo-VHj^inul si-[>tuiii, Uie se[)aration is easy and the l>isl< 
no longer recjuireii. It (uily reniains to luKik up tlie free ant« 




ANTKBIOR rOM'tlHRIlAPllV 



lU 



I 



pari of Ihc flap with the index finger ami lliunili of the left hiiml 
uiuldfttudc byiiiniplt/ rolliiiy hurl: (hv part« \\\\\v\\ sefmrate easily. 
The (lenu<)alioii is [«>rfarme(l first in the median line and then 
laterally, until the flap is quite detached. This method is pref- 
tTitble to that of scissors or liistoury. Then* is less eliance of 
injiirinf; the bhiddcr l)ecause one works in a favoralde plane of 
cleavage, and the hemorrhage is less. It is also more rapid which 
is of importance in anterior colfjorrhapliy, as generally it is one 
feature of a more complex operation. 





Vw IS2 — Antorior prr-cnrviol col- 
fituphy. DcnuJed twli^e^, stltcbM 



Flo. ia;j.— SliioliL'S Ui-A wiih iho KX- 
eeptiob pf tilt' liinl puroL'-Btring mituro 
whici) will cUiAi; thr ori|[iiiul rcntrr "i the 
(hi««-brutialivil nlMLt, 



Union m obtaine<l as in all plaslir (>[>cra1ions. The needle 
lltQuld jienetrate below the denuded surface. 

We use catgut in place of non-resorbent material such as 
rilkworni gut and silver wire, as removal after contraction i.s so 
'liificult. swing that colporrhaphy is so often combined with 
[fKneorrhaiihy. Wc pivfer the (-(mtinuous suture which i.s more 
f*f'id. This is done easily with a medium Ilagedorn's needle 
"liii'h one can take in the hand. Important to remember is that 
*c commence by the inferior cxtrcntity (cervical) and progress 
l'» live superior extremity (urethral). The parts are brought 
'•^■Uier when sutured and the non-.sutured [wrtion remains 



166 



PLASTir OPER.Vnn\S OS PEIUNErM AM) VAOIXA 



easily accessible. If, on the coTitrans one eomniences nt tlie 
tirellirul extremity, the cniilraclioii of the uiiterior part of the 
vagina wouhl iiitcrfcre with the pas-sage of the sutures. 

Most often u sinfjle suture plHiic is enougli ; whi-n the deforce of 
the cystfM-eh- Ims h-d the op<'nilor to do an extensive (U'liudjition. 
the tension of the tissues forces a suture by slJiges; its execution is 
easy. Begin with a premier line of stitches which are introduced 




Fici. 1:14. 




Fin. 136. 



and appear in the denuded surfaee. and ihus produce a fold of 
the vesical wall; tlien one sutures the non-united parts aljove 
this fold, taking up in passage tlie deep plane to avoid cavities 
between tlie two planes. 

Various Procedures.— Wc have dpHcrilwd <>iir ii|ifTali«ii. Wi- rmnlii to 
A<ld timt all sorts' of [lenudfil uroiiN have bcca dcst'ribcd and alJ inanniTof 

' Sec Charl^K G. Child, In The Revic-w of Cj-ntowle in the I'ast 100 Ytian. Amrr. J. 
ObtUl., New York. 190Q, T. II, p. DH. 




A^TTERlon COhPOFlRlIAPHY 



107 



I 



tutuKs. Wiy gi) into lh<-m? We coiinMlpr ll«rsc- i-miijilifttled 5utur(^s 
should give way to the !>im|ilc continuous suturr or that by liiyvrs. 

Anterior Prtcfrfietil Ctdporrhajihii. — In nonie caiteit nf iiiiteflcxion mtk col- 
lap*t of the- anterior tnginal u-atl. forming at llti- Irvcl of the tuttirior 
fiirnix a iirominrncc ninrv or lets niarkod, \vlti<-)i liiili-s tJie os. Dol<5ri!)' 
•dvitics a little anterior prv-cervicnl coljiorrliapliy. Tlir denudiition is Iri- 
■nguUr. The liwe corrrspontJs lr> the an^jle of reflexion of Uie vagina on 
llietrrrix and mcjuures 5-4! cm. Tlic s'uW's have tlir sunic len^^h uiui 
the !<umn)il is abciiit the niiildlc of the anterior vaginal eolunin. L'nite each 
oC the three angles br two or thmr separated stitches, thus making n star of 





Flo. ISiQ. — IricUioii (urilm riplit- 
Uiifi ofllivumtJiro-viigmalicpMini. 



l-'iu. 137,— Silt iirfo( llie k'VnlorB 
At. tli<i IrvcI of tlii^ iipUUiiig of tho 
urvtLiru-VAgiiial •eptum. 



li>KC t>nuteli<.-s and Die et-nter is closed with u purses t ring suture (I^gs. 
Wuid 133). 

Tlie ragina) jiurliun of the cervix is thus freed and n solid support is thus 
■uile Wlow the bladder and causes it to remain anterior to the nterti^, 
*ni| Mipports it. It pre^tscs the uterus iti asense backward and helps to 
•"rrmme it* anterior flexion. 

Combination o/ Anterior Coijiorrfuipfit/ iriih Amputation of the Cervix. — 
wlon C^ioke Hint* inaisU on thin fuet that the un>-genital tliagihragm 
«i |iraUpse is lorn both anterior and [xtstcrior to the vaginal orilici?. He 
'iMmmentLi beginning by deiiudinif the tmtrrior i-atjitiul (friioveit exactly as 
W iNMterior are done in cul[>o-p(;rineorrhaphy. Insert sutures but do not 
''t&etn at odc«. Fix forcejis to them an<l put the foreeps un the puhi:*. 

Oraw the cervix out of the vulva and make a large lietnidation anterioHy 

'IMtri*, TmatnwnL tA Stcrilitv. Th. de Paris. lS9S-lS9fl. 

'.Btctoa Qwkp Illr*l, A Conlnlxuioii iti llio I'ffir'iuncv of Plastic Oiierations oa tli* 
ArMT.J. of OitMtttriit. New Vork, IBOS, T. 11, p. 100. 




I6S 



PLASTIC OPER,\TIOXS ON PERINEUM ASD VAGINA 



shaped lik*- » xtiii-ld willi hnxc nl tlic rrrviii And the tcip [miiM'i)tuU-1\ licldw the 
urethral orifirc. ThU flap U di^scctrd up and cxeUcd ^Hg- I34). The 
cervix is amputahd. I.nl<-niliv sc|tiiratf the li^mtm a.< fur hs the uterine 
ligament:!. 

A con I ill no 11.1 nutunr Jn «evi-ni) Inyers iniJIirs the ilt'niidril vugiriiil surfare; 
the stump of the cervix is sutured as in Hegar's operation (Fig. 135). the 
most Intend )iutiire« Inking np llie fihro-nmnritlar fimiufii of Ifie batr of the 
broad llgamenls in .lurh n manner as to obtain a firm hold of them. The 
iitcrnx i* put buck in pliice nnd the sutnn-ji inwrted in the unlrrinr grooves 
and tied. 

Spliflinij of the Antrrinr Wall of tlir Viujinn ami Suliirr of fhr I.rvalor». — 
The iittiirt iif thf ki.ators ctmimon\y practised to-day in col po perineorrhaphy 
wdsadvocatcd in the treatment of liysterc>celeb_vl)i'l«HgI«de.' then by Ci roves' 
and by C'haput,' It is done anterior to the vaginal orifice ami directly below 
the bladder. This tinterior repair of tin- iimsriihir pelvic diaplirui^m has Ihe 
advantage of placing the bladder on an claslie and norniul conlrHclile floor 
and of pushing back and tip the cervix uteri and thus correcting the retni- 
deviation which ucc(K!i])ariies prolapse so often tFigs. I3B ami 137). 

A tinger's breadth behind the inralns make a transverse incision the whole 
width of Ihc vagina. Separate the bladder and then search for the levators. 




Kiu. l.TS. — f reund's u)>erntion. 



5. Constriction of the Vagina by Metallic Sutures. 

Freund'' has tried to obtain constriction of the vagina by 
a series of fibrons rings around win's maintained some time in 

' DcUnnlwlp, Bull, rr Mft». de la Nor. df Cltir.. I'uris. I9tl2. p. I UO. and 1905. ii, 361. 
•Groves (ICfui-Bl W Mevl, Joiiriiai ••/ Obtifl. and Oyi. />/ finmlt Kiapirt, iflOS, T. 
VII, p. 1S7. cl .Inn, dr fW"- fina. 11)05, p. 367. 

■CliiLput, BttU. 'I. Mim. lU 1.1. ■inc. dr. Chirurg.. IVl», IWA, p. 337. 
•Frt-uni). VrnlT.-BlaU.f. Ggn.. LeipwR. I8»3, p, 1081. 




COLPECTOjUy 



16U 



I 
I 



position. Aftrr IcK-al aiu-stlu'sia lie insorls ins first wire as in (lie 
figure near the Insertion of vagina on tlie cervix. In tioiiig Ibis 
he usos u curved newHe wliicli is introdiUTd into the subniucoua 
tissue as far as possible. He brings the needle out and enters 
again in tbe .same point and so continues until tbe nec-dle comes 
out in its original jminl of entry. Ilr now dniws upon it until 
only a narrow vaginal space is left and tiien lies il. The wire is 
cut vorj' short. A .series of these sutures are placet! from the 
cer\'ix to the perineum. 

Tbe.se sutures have a double action, acting a.s mechaniral 
irriluiils and finally a cicatricial ring is formed. 

a. Colpectomy. 

Conceived by Le Fort' and Xeugebaucr.^ who excised two 
little quadrilateral flaps of mucous membrane on the anterior 
and posterior walLs and tlu>n t)u; anion of the denuded portion 
with silver wire sutures. This operation results in a band of no 
great thickness which speedily gives way on pressure of surround- 
ing [wirts. The procedure of Dubourg'' who substitutes a trans- 
verw in.stead of antero-posterior septum of the vagina. 

We have modified the operation in the following manner: 

The |)r()lapse being drawn completely out of the vulva we 
excise on its anterior and posteritu* wall two huig and broad mu- 
cous membrane flaps. Commence at the cervix, and terminate 
anteriorly near the meatus and |)osteriorly near the fourchette. 
We .suture the two denuded surfa<'es with burie<i resorbent 
sutures, commencing at the cervix (Fig. 189). advancing to the 
vulvar orifice, pushing back Ihe united tissues .sc) tlial when the 
last .stitch is put in, the prohipse is completely reduced. Figs- 
l-IO. 141, 144 show tills putting ba<'k of the prolapsed |>arts as 
they ape progressively sutured. 

Wc thus create a long cicatricial column Hhich occupies almost 
the whole length of the vagina and which is unich nu>re efficacious 
than the liltJe mucous membrane baud described by I<e Fort. 

' JUtdrt. Dg Traitmeint du proltii)«iu uWrin par le ptocM* Ue Le Fort. Th.df 
Paris. I88». "^ ' i~ f 

■NtninbKUar, Cfntr.-Bt.f. Gyn.. INNS, |i. 0, 

* DMnicr, 8u|>Ariori<# ile« o|)#rauuiiB »ur li' vitgin et d'uue nouvelle vp^rstiuii, en 
p*rtiinili«r dana l«s prutapHus uUKns. Th. lU Bordeaux, 1893-1^94. 





TKEATIIKNT OF lUiCTD- VAGINAL FISTULAS 



171 



Muller' advisetl the totui removal of the voginu. Tlip prcilapsc 
beini; drawn out lo a maximum, lie then oiake.s a (-ircular iiiriKion 
of the mucous memlintne at it^ base going abiivc thv perineo- 
rulvar groove posteriorly, and a centimeter from the meatus 
anteriorly. From tliis incision he strips the vaginal mucous 
iiieuiliranL' in its whole extent, amputates tJie ei-rvix. stops the 
bleeding and inserts a series of purse-string sutures into the 
ilenudci) surface, from cervix to perineum, pushing hack the 
tissues as they are sulni-ed. 

When the last stiteh is inserted, close the vaginal entry with a 
sagittal suture. When the operation is finished there remains a 
little cul-<le-sae 2 or 3 cm. deep which is tamponed with ioiloforni 
gauze. 

It seems natiiml that secretions should form above the eiea- 
tnciul ailumn. That is nothing if the o]>crati()n is done on 
Women after the menopause and if the colpectomy is preceded by 
curettage and a cauterization of the uterine cavity witJi carbolic 
acid. Konig^ had one death in 30 cases, following infection 
|»roduce<l by pushing her hands into the wound soon after the 
operation was done. She was old. 

^^^^K 7. Treatment of Recto-vaginal Fistulas. 

■ Recto-vaginal fistulas present very diff'erent anatomical condi- 
tions. They may W high or low. nslial or carud like. They are 
**sy or difficult of access according as wliere the vagina is wide 
oi" narrow. The oi>erations are also wry diverse. Simple 
^uterizations are rarely successful. Their treatment by the rectal 
i^ulc (I)eniarfjuny) or l»y the sacral route (Ten'ier, Heydenn-ich) 
"as lieen alwindoned and now tliere are two routes by the vagina 

k*il«l itcrineitm. 
1. Operations by the Vaginal Route.— Simple denudation 
'"aped like a funnel, with its sumniil at the rectum, followcil by 
'*iini(»n of a single line of sutures, being careful not to perforate 
"ic intestine, has given success. Schauta prefers a large triangu- 
»tr denudation u ith sutures at some distance. The fistula in 

, ' Wanant. Die Knipcciomif «ur BcrichtiKiinK da I'talnpfun liltcref I'raucn. Man. 
*• (M M. Oyn.. Berlin. |s!)S, T. I. p, M7. SavHriniii), L'ujijratioii (l« Mull(>r pour 
t*riyt. AHitatet /It ffyMrvSofiU. Hnris, 1601^. p. 1)60. 

'Uiuc. Mailer'* .Mi-thod of Colpcctoniv fur lUoniic Oollaiwo. Journal of Obiiei. 
HJfftM. </ BritUh Empin. XWA, p. 305. 



172 



PLASTIC OPERATIONS ON PERI.VF.rM AND VAGINA 



the ct'utor i>f this liirjjf di'iiuilctl surface is closed I»y manyl 
sutures wliieh do not [lerfomte the tis.sues in lis immediate 
vicinity uihI tlius irirri'iisc the clmnccN of reunion (Fig. 143). 



Flo. 143. — Procoduro by triangular dtniid&tioi). 

Others have recourse to splitting of the recto-vaginal .seiitum, 
some ]>rocee<J from tlie fistulous orifice (Sanger), others lol 
do the sejMirution at some distance from the fistula (I)oven). 
lu order to prevent fecal matters from getting in between the 



M=-' \ 



V^S? 



Fiij, 144— Ppoccdiiri' by Bplittinn of 
tke ipptum, UUck liiioi <[rnoii' tlio 
Ineiuitn. lli« dolt«>i tho llniitH u( ihc 
■I>lllll>iC. 




Viu. 145.— Pnioediiro hy Hplittinn;. 
(l(«cp noutinuiiiu »uturt !■ ti«d. Tbi> ■uprr— 
flcial (ilitrfil but not Uod. 



lure* 



opposed surfaces, Sanger niake.s a complementary rectal sut 
After dilatation of the anus he presses Imck the septum with i 
finger in Uie vugimi in such a manner as to cause the listulou 




TREATMENT OF RECTO-VAGINAL 1-ISTULAS 



173 





Fio, 147 — Flni> ■IUmoiIhI and liirnM) 
Imck. The tloiteil Una di-notrfl (bt^ i>iir- 
tian> of tihc venlMl wntl wliicli will hv 




Fni. H9.— Bcellon of 

tlie rvolo-VAKUUil MpttUD. 

T)i^ "ut lire \* ti»d ona roll 
u( Ka<i>^ >"> BH nol to nit 
thntiiRti. V, vu^a; 11, 
roetum. 



174 



PLASTIC OPERATIONS O.N I'EltlNEUH AND VA43INA 



orifice, already suture<l vaginally, to ap[)ear al llie level of Ihe 
anus, and he llicn inserts some stitelies iiitn thv rectal mucous 
membrane which he foMs up above the sutured fistula. 

Fritsch and Ije Denlu advocate autoplastic operations by use 
of rt vaj;iiial flap. I)ut while Frttsch takes Uiis flap from iihove the 
6slula, I^ Dentu tjikrs it from below (Fig. 146). In the latter 
case to avoid the formation of a cul-de-sac we should In-forc 
inserting the sutures resect a triangulnr-sbn]>ed portion of the 
rectum, uitli its sunnnit ut tlic fistula and base corresponding 
to base of the Hap (Fig. U7). 

Some stitches, tieing careful not to perforate the intestine, 
suture the flap to the denuded surface. 

2. Operation by Perineal Route.— In ihLs operation we 
coramcncc by cullin;; through all parts of the perineum subjacent 
to the Kstula which is cither scraped or excised. We Hnd ourselves 
thus in the {losition of dealing with a complete perineal rupture 
and treat it accordingly. 

Without culling through the |ieriucum separate it up to a 
point just above the fistulous orifice and then after suturing the 
vaginal and rectal orifices as in perineorrhaphy with na[>s, leave 
in a gauze drain which lies between the penneumand rectal suture. 

in cases of extensive and high-placed fistulas. Segond advo- 
cates the resection of a portion of rectum subjacent to tlie fistula, 
followed by the <lrawing down of the upper end which descends' 
like a itlind lichin<l the vaginal orifice. This latter is denuded 
and suliH'cd apart (Figs. 150 and 151). 

(ieranl Marcband's <ipenition might be applied to certain 
rccto-viiginal fistulas. He cni]jloys a certain technic for recto- 
|>erincal fistulas and this consists in (Irawing down the rectal 
nuicous nieinbnine alone in front of the fistulous orifice. After 
ilihitntion of the anus, (J. Marchand' everts its mucous membrane 
and incises it 1 cm. above the ano-culaneous line. He dis.sects 
the mucous nienihrane by the aid of his finger and the blunt 
extit'iuitv of the scissors. He draws it down until ho is able to 

« 

cut through it above the fistulous orifice and then he attaches 
this drawn doun mucous membrane to the little collarette of 
mucous membrane pres<>rved in the anal canal. 

* n«>mri) .ICftreluuid. Pi>riii«<i- Mid [{ccto-vmgiiutl I'liitulaa. Tr««tnieiit by Urawinx 
tVivn of tlui iliHK»uMeiiit>Tiui« ol Um Roetum. BuU.ti. .V«m. 4t la SodU i^ir., PuU, 
l«KI, |> ia\. 



I 




TRKATMEXT OF RECTO-VAGINAI. FISTULAS 



175 




Pfo. 150> — 8«icond'a prooedun \>y drawing Fio. 151. — Segund's prooeduro. Oper»< 
down the mttuin. lion trriniiiiitcd. 




,!•• I52-— LtRUim'* prowslure. Ttie ^•riiieuui hua Iweii divided, lite dcntidcd 
fanoM ^^^ beeu *plit bh far as the fiituln in nucli a wfty m to expuac thn rcotal aurioM 
pUinljr. 



176 PLASTIC OPERATIONS ON PERINEUM AND VAGINA 

3. Operation by the Vagino -perineal Route. — Legueu' splits 
the perineum just up to the level of the fistulous orifice, and then 
divides the denuded vagina longitudinally as far as the fistula. 
By this wound, which gapes widely, he sutures the rectal orifice, 
and then he terminates with a colpo-perineorrhaphy (Fig. 152). 

Indications. — These various procedures we have just de- 
scribed have different indications; each one corresponds to a 
particular anatomical disposition. For low-placed fistulas, the 
best thing to do is the division of the perineum followed by 
its reconstitution ; for high fistulas, the o|>eration by the vaginal 
route. It is very evident that the state of the perineum has as 
much value in the choice of the operation as the height of the 
fistula. 

' Legueu, ThcVagino-perineal Route in the Cure of Highly Situated Recto-vaginal 

Fistulas. Preane niidicaU, Paris, August 26, 1908. 



CHAPTEIl IV. 

OPERATIONS ON THE CERVIX UTERI. 

Summary. — 'IVmjmnir)' or drfinitc rurhwion of tlir ccrrix, — Tcrnportiry 
drfinil*" Irarhelotoiny. — Cimrlv's and I'ozzi's opera I ions. ^Trnrliclor- 
kphy by dcn»r]H(iori nr fliijKs. — Ainjnilutioii of the crrvix. iiifritvuginnl 
V«rtlh two flii]>?( or one flap), supra vagina I. ^Various o|>eratioR<i (sea rill rut ion 
of ihe cervix). — Boiiilly's «in) Poury'jt opi-mtion.^Oprriilions for uterine 
Scxions. — (.>|>erations on the cervix and pregnancy. 

Till' ojKTations on the cervix are divided into: 

I. Ojx-ralions to [jroducc tin* occlusion of tlic cervix. 

9. Ojiorations to cnlarjje the cervical canal (truclu'Iotoiuv). 

3. Operations to repair the torn cervical canal (trachclor- 
riiaphy). 

4. AmpHtation of the cervix. 

1 . Occlusion of the Cervix. 

The occlusion of the cer^'ix may ''f' temporary or definite. 
The lemfXirary ocditsion may he done with two or llircc sutures 
nriinitinj; the two lips of the cervix, perhaps with the aid of two 
.MiLseux for(-ep.s which maintain them in contact. 

This temporary occlusion of the cervix is done as prclinii- 
aarv to a vaginal or ahdoniiual hystercctotny in order to i>rcvent 
infection from a septic uterine cavity. It is also done for a uterine 
hemorrhage or to maintain the provisional reduction of an 
inconiplvtciv rc4luced uterine inv»Tsion. 

All lliese indications are exceptional and in practice the oppor- 
lonitv rarely pn-scnUs itself. 

The tiefinite occlusion is done by denuding the lips of the 
cervix and then uniting them by some sutures. It has been done 
in cajte of vi-sico- or utcro-uterine fistulas of a rebellious ty|H-'. It 
U B hH<l (>iK'rnli<ni and has been abandoned. 
u 177 

I 




178 



OPERATIONS ON TITE CRRVIX UTERI 



2. Trachelotomy. 



dl 



Trachelotomy or ineUion of the cervix uteri may be, as in 
occlusion of the cervix, temporary or definite. 

'IVrnponirv trachciiitomv mav be carried out on the cervix 
itself or on cervix and body both. Limilctl to tlie cervix it consists 
generally of a commissural iiici.sion which is done with a simple 
cut of the scissors. 

If the trachelotomy includes the body of the uterus, one may 
have recourse to the iiu.-isinn of the commissures; one nnist lie 
careful when at the level of the isthmus, not to go beyond it on 
the external surface of the uterus, and even at the level of the 
body to be careful not to injure the uterine artery which is so close 
to the border of the uterus. 

rioine operators prefer to the bi-commissural incision the 
antero-median incision of the organ after disinsertion of the 
vagina and methodical sejuiration of the bladder. 

Temporary trachelotomy may be done during an accouch 
ment in certain eases of rigidity of the cervix. It consists in 
commissural incision, either simple or bilateral. 

Rejected by a number of accoucheurs who ri'prnaeh this 
incision as tending to produce extensive tears during the pas.sagc 
of the Iicad, the operation is rarely jjraetised. In any case suture 
the cervix us well as ))ossible after accoueliemeiit. 

It i.s exeejitional to do trachelotomy in order to explore the 
uterus, as simple dilatation replaces it (piite well. Again, incision 
of the eervix is sometimes the indispensable preliminary of a 
myomectomy jK-r I'uiit luituralen.^ I 

Definitive trachelotomy aims at enlarging in a permanent 
manner the orifice of the cervix constricted by an accpiired or 
congenital malformation. Wiatever means are employed, aim 
at a new orifice of sufficient dimensions and with no tcndeiny to ,; 
contract. \ 

'I'hat is to say, reject trachelotonn'es which only consist of 
simple incisions; also see that (he incisions are made with an ' 
instrument comparable to the lithotoine, or Simpson's metrotome ' 
or Kuclielmeister'.s special scissors. ' 

Fritsch's operation consists of a crucial incision of the cervix, " 

' Sec Vugitml Myomeolomj'. ■' 




179 



followcfl I»y tain])oiung, and Ivvciily-four hours after destroying 
the points of the flaps with the titer inocaiilery. This isstJiKrior 
to the aforementioned procedures hut is nevertheless unworthy 
of preservation. 

It is quite evident that autoplastic procedures may ^ivc a 
definite enlargement. They are all based on a general [jrinejple, 
never to teaiv a rawed surface after section. 



Via. 153. — KOdhelmeUw'a Bofaaora. 

This result is obtained in two ways: Courty's type aims at 
covering the surface of the section with an autoplastic flap, and 
Pozzi'a followers unite the mucous memhrane of the vagtTial 
surface of the cervix to the endo-ccrvical mucous membrane. 

Courty's Operation.- — Commence by two triangular and 
*Tmmelrical (laps on the cervix, summit internally and base 
nltrnally. Each of these flaps is limited by two incisions which 
ait United al the level of the corresponding coniinissure of the 




Pic. I&t. — DUaeellon of two IriaiiKuIiir am] nymtix-lririi] mucouii Rapt, 
ec'o', l>l>'o" , fi, "iriflfc III tlie ct-rvla. 



'wvix. These flaps are dissected down from tlieir sutnmit to 
llicii Iklsc, which base is left adherent and corresponds to the 
junction of the cervix and the lateral vaginal foruiees. These 
|fl*jw are rai.sed and their cervix is incised bilaterally at the level 
^ it* commissures. The auto])lastie fla|ks an- now laiti down 
•n the depressions thus created, and with a catgut stitch the 
'^innoit is fixcil to the endo-cervieal nm<-ous membrane at the 




180 



OPERATIONS ON THE CERVIX UTERI 



actual Ifvol of the floor of the dihedral angle.s thai represents 
tlic iiu'ision. 

Additional .sutures unite the anterior antl posterior Imrders 
of the flaps to the mucous membrane of the external surface of 



PlO. 15&, — A deep bilateral incision <-xt«[id« from t.hv iinrraw urifiae of the oervlxt ' 
a. to llie midille uf tbo b»sc uf Ihc U'inngtilnr &np% tt'o'. Wo". 

Uie cer\'ix. The lateral incision of the cervical orifice is thus 
covered with mucous meuil>rane and no portion rests on the 
rawed surface. 



Flo, 15a.— lliiT noinlA of tJip 
Ha pa a'o" htv livnt l)»ok into ibe 
aagl«ii of tlip coinniiBBunil inci- 
»ion of the er^vix ; (our 
dUtchc^ two ftliove an<l two 
below, fix the (laps in llio iiuw 
cominiBnirc' rcsiilling from thr 
liivinioii. 




FiQ. 157.- — Tlie points uf l.lie flaps o' 
o". jiM-KiPii into tlio new comniissiircB re- 
8u1litiK from divwion, are niaiiitAined 
thori^ liy K butloii suture on cnoli aide. 
The oprration ik complrtnd. 



The idea of implanting a mucous flap in the wound pro- 
duced \ty the division of the stenoscd e.\ternul orifice has been 
taken up bv several other ojwratoi-s, by Ro.ssner,' who cuts the 
flap at a certain distance from the external orifice (Fig. 158) and 
' RoBsner, Cmir.-Bt.f. Gjfn., l-eipsig. 1897, p. 210. 




TBACHF,IX>TOMV 



181 



!>y Mars' who hikes Ihem like Courty from each side of llic 
orifire (Kips. 15i)and 160). 

Pozzi's Operation.— ^Th is is known often as gfomatopiasty, and 
is done as fulhiws: 

The ecrvix lieing exposed hy vajiinal .S|)ecula. place on earh 
li|> a pair of bullet forceps and then with a pair of strong scissors 



m'- 



sv 



fiq. 16T* — To ihc rinht ii wcon tlic 
mtbUoa of iho flap, to tbe left t)i« Ha]) 
pnMd bock into tfa* conuniasurBl Mplit- 
lin(o( (be ocrvix. 



Flo. 169— To Hie left Ihe (!.■»[> hw 
been Iiiowed and to Uie riglit tlie flap 
(liMeotod (Mu>}. 



j//>a 



m 



if'. 



Fu. ISO.— To tbc left thi» flop U rui-iil iiii; ui the ri^ht, prcMod down on the 

deuudi-d air*. 

•ttake a hilaterat dicision of the cervix of 'i or 3 cm. Dilate the cep- 
^t»l canal with Hcfjar's iMHi^it's np to No. 20 or 30. This is 
*»s\", owinjr to tlie preliminaiy spliltinjj of the cervix. 

The eavitv of iJie cervix liciiij' tlien easily acc-essihie, excise 
■rom the lips two trianf;ulnr prisms, leaving a band of mucous 
toenibrane in the median line. Two or three sutures of silver 

'Ham. /&Mbin. I>.21». 



IS2 



OTERATIONS ON' TIIE CERVIX UTERI 



wire are sufficieDt to close the grooves |liu.s created m uniting the 
InttBtrerrical mucous membrane to the vaginal (Figs. l(tl. IGi, 
■unl !(»). 

'rhtr upemtion when finished shows the cen'ix like u duck's 
hitmk iwltlv open, but gradualty its form changes by retraction, 
and linsUY it cumes to look like a normal multiparous cer\'ix. 

'ITtof dressing consists in placing a piece of gauze between the 
U(W «iHi in tamjioning of the vagina. This is renewed every 
k:wv or tlucc days. The stitches are taken out in five days. 



I 



y*x. vt 



fe»<««I 



s^". 



Flo. 183: — B«ooncl«tu;i<. 
ExcUoa of triunculkr 
nriun from cmpH xiilc of 
tlw etrvirnl c&iiaI 




Fio. 163.— Third ataiEn. 
To Uw Irft oomtnoae^ 
ment oi the luture. To 
the riehi opcmtion com- 
ptotod! 



S. Trachelorrhaphy. 

ft|Ay U the name tipplic^l to the measun*s 
tvy«tW*(«t^ vl ^r« «^ th** t^'fvix. Kvcry trachelorrhaphy has 
m%««SK^- (V «K*nvt«lation and suture. 

tVK'Av W^wni; *'<'«• «">■ inflaniinator)' lesions which may 
Ms\\t ■* ' " '"'■' l"(*n»'«' U'fitn- llicir cure. 

K , , .» intiUnilrtl. everted and rigid, commence with 

ft l^r<4imi«»'? *"**>"*"'*'• ■*'"''' "'^ ''"* inj*H'tions, a scarification of 
iliUM cer>'ic*l f»>llh4rs. ami glycerine tampons. OiUy <lo thci 
tiiirMrtn4>fi»A'> ***'^* *''*' ***'"''' *'"* •^'^o^^ supple. 




TnACHKLonRHAPtrV 



183 



As for Ihe perinc^orrliaphy, we find two iiii-tIio<i.s; viz., .surface 
ilenudation iim) deiiudution by !iplittill^^ 

Trachelorrhaphy with Surface Denudation. — 'i'lii.s i.s tlie 
Emmcl type of opcralioti. It consisLs hi dcnudution uf the tour 
with excision of the .subjacent scar and then reunion of the rawed 
surfa<'»^. 

Tlie two cer\'ica! lips are seized with two Museux's forceps, 
which draw down the parts ami atso Kcparatc them. 

\$ it is iniporlaiit to cxcLse all the cicatricial tis.sue. [tarticularly 
althe level of the .superior angle of the tear, where there i.s often 
a rigid and fibrous scar, it is well to coiniuencc by an incision at the 




JM- 



Fie. Ifl-I.— TrncholorrlmiAy bj- 
<l«)uilnliuii. To tbo left is thif 
deuudation adiI to tho right Uie 



Fio. 1(15. — 1 •piTftti'iri iiiiislied. 



lewlof each angle, until one (ind.s hcaltliy subjacent ti.ssuc. This 
IS (lone with a ]>ointed bistoury. The denudation is accom- 
plBbed by the excision of the flap. 

■Wtor tamponing to .stop lieinorrbage unite the rawed sur- 
face with about four catgut stitches, ]>a.s.sing througli all the 
tfcickncss of the cervix and tied externally. The .suture is 
mnunenced at the su|>erior angle of the wound and finishes at the 
"eternal orifice of the cervix. .\\\ these .sutures should lie in.scrted 
•»forp tying them. 

If Uie tear is bilateral repeat the same operation on the oppos- 
uiR Mile being careful to preserve in the median line of each lip 
* lAi»d of mucous nienil)rane about 1/4 cm. wide between the 
lion of incision in order to re<'onstitute a cervical canal. 



IS-] 



OPKR.\TIONS ON THE CERVIX UTKIll 



Trachelorrhaphy with Flaps.^Trac-licIonhaphv «iili flaps, 
dcscrilu'd hv Saiijjrr ami pructist'd hy Fritsdi and Klcinwat-hter, 
is much less employed. The triangular flap, with inlraeerviciil 
base, is cut at the expense of the mucous memhraiie whieli covers 
the tear. The resection is carried out toward the cervical canal, 
and the denuded parts are utiiU-d (Figs. lOtt ;nid 167). 




Fill. 18li. — TmclK-lorrhnphy irith fittps. 
DiiiwiMinn and raihiriK ijf Llii.' Iltip and in- 
ttcrliuu o( suturtw. 




.:-.«*^ 



Kiii, I6T.— The Bi.itfhi\s iit. 
nieiidiiji by thoHt^ furllii-i 
the orihce nf the cervix. 



1J||| l"!!!!!. 
V, :n frum 



■i. Amputation of the Cervix. 

The uterine cervix is in part supravaj^inal and in part intra- 
vaginal, and the distinction of infra- and supravaginal depends 
upon whether llie operation is done lielow or above a |»oint of 
reflexion of llie vagintd mucous menilirsine on the cervix, which 
is indicated hy the difference of eoh)ralion of tJie iinicous mem- 
brane as also by the folded aspect of the vagina which contrasts 
with the smooth cervix. 

A lafravaginal Amputations. 

Tiiis was first done in a very rudimentary manner. At first 
the protruding portion was cut through transversely in the vagina.1 




AMPUTATION OF THE CERVIX 



185 



Later the parts were sutured. Simon suturwl tlie vaj^inul mucous 
meraUrane Jitwve the rawed surfac-rs, having l)elwt'fn iJic united 
roucoua menibrnnes and the surface of the section a virtual 
cavity. This cavity was exposed to consecutive hemorrhages 
and to an irregular cicatrization. 

Hef^r made great progress in the operation I)y suturing the 
va^nal mucous nicnil)rane to the intracervical. 

To-day the most frequently practised is two-flap amputation 
or the one-flap. 

The Two-flap Amputation (Simon-Marckwald). — In this 
operation which i.s nio.st apjiticalilc t(» large sclerous cervices 
wilhout any lesion of their lining surfaces, a wedge-shaped 
excision with the apex above is made from each lip. The 
operator now cuts thn)ngh the vaginal surface of tlic posterior 




../i 



.i«; 



'---!■■ 



Flo- 108. — The two-flfip ampulatior of 
Ui* otrvU. The coiomiitsmiiMi nre »pbl 1)1- 
UlrTkllF. Pmia caoh lip innxciicd u oiind- 
torm MKincni of Ihv ci^rvix. 



Via. 109, — Opemtion finished. 



lip from below upward an<l from lichinrl forward, .\fter tliis 
the [losterior lip is again incised, coinnicncing on the intracervical 
surface an<l directing the knife u[)ward and backward until it 
meet^ the first incision. He thus excises a cuneiform segment 
of the cervix, which leaves two flaps facing each other's denuded 
surface and covered on their opjjosing surfaces, the one by 
intracervical mucous menibrane and the other by the vaginal 
wucfMi.s membrane. 

Nothing is simpler than to suture the two flaps together 




186 



OPERATIONS ON THE CERVIX UTERI 



with a tion-continuous suture using h strongly curved needle. 
The only ]>rocauUon is to pass the suture under the denuded 
surfaces in order to avoid virtual cavities !>etween the flaps. 

When the iiperation on the po.sleritir lip is Hnished, the same 
procedure is carried out on the anterior lip. It only remains 
to insert a suture in each lateral eoniniissurc and to ilo the drC'ts- 
ing which consists in a light tamponing of the vagina willi iodo- 
form gauze (Figs. 168 and I0»). 

The One-flap Amputation (Schroder). -As usual the lesions 
which demand operation are niucli more marked on the intra- 
cervical mucous niemlirane than the vaginal surface of the 
cervix. There is an object in removing the diseased mucous 
membrane am] to cut a flap entirely at the expenst^ of the ex- 
ternal surface of the cervix. Thus Schroder's operation realizes 




Flo. 170.- 



illpUtAtlOD. 



Ftu. in.—Tbi* fla{> i« nplMwd. 



this and it is very coiimionly done. In ihi-s ojMration the re- 
sected segment comprises all the iutracervical mucous mem- 
brane and the greater jmrt of the cervical tissue (Figs. 170 and 
171). It has been advocated to make the resected segment 
thicker in the neighborhood of the internal orifice of the cervix 
than at the other extremity so as to give more suppleness to the 
|M>rtion of the flap, which ought to fold back on itself, on tlie 
surface of the si'elion. 

It is simpler we believe to cut ofi' all the muscular tissue from 
the flap antl only preserve the mucous membrane on the vaginal 
surface. Thus we have quite an elnslie flap which applies iLstrlf 
exactiv to the rawed surface and which mav l*e fixer! without fear 
of Uic least traction in the sutures (Figs. 17'^ and 173). The 
operation is done as follows: 



1 




AMPl'TATION OV THE CEKVIX 



187 



The cervix haring lieen as a preliminary curettMi, so as to 
facilitate the jmssa|;e of tlie suture needles and Uie insertion of 
the sutures. Curettage U necesjtary on atTount of the cemcal 
metritis which usuallv exists and of inflainmntorv lesions of the 



IkvIv. 





I 



Pio. lT2:~Tln- flnpUfurauHl tFxclii.i- 
irrly «( ihe vKgiiikl mucou* mcmbrHiM-. 



FiQ. 173. — When the buIutc it tight tho 
rnxtnul muvoua mcmbr»nnB will stick to 
llie sei'liuii iif thi" ciT\ix. 



After curettage draw the cenHx down with two Mutseux 
forceps applied to the anterior and posterior lips*. Then incise 
with single cuts of the scissors the two corainissurcs as far as 




174.— The oerviit Iim betn apUt bllRteraUy. Tba knWrlor Up hu been exeitod 
but the vn^nol rouooua membrMio hu been praserved. 

**'! vaginal insertion und thus divide the cer\'ix into two so-called 

Still drawing on the [Hwterior lip of the cer^'ix forward and 
'^I'ward. ex|>03cd to our view is the vaginal face of the anterior 



188 



Ol'KRATIONS ON THK CF.RVIX UTKRI 



lip. At the level of the free border or a little more externally 
if tlio lesions encroiicli on the ulcriiic orifice, tin- nuieoiis mem- 
brane is incised with a bistoury and then separates off the> 
musenlar tissue of the cervix nntil wr reach the p(»int where we 
wish to inukc tlic section. Xow cut this throiiuh transversely 
and then insert the sutui*es. 'I'liree <'atguts will suffice. Do 
not \ye content merely to insert tlie.se at the level of the free 
border of the flap, but to pass right throujih the deep surface, 
even to the surface <»f section of the cervix in such u nuinner as 
to avoid a virtual cavity below the flap where oozing may occur 
(I-'ig. 174). I*ull the sutures light to assure hcmostasis and the 





Fl o. 1 1^ — .futures i n- 
Mrt«d iiilo tilt! niit^rior lip 
tn cut lonii oJid nerve lo 
dr»w on the cervix, of whidi 
thv poatfirior lip bus been 

«XCiM>il. The v>|[iiinl mu- 
cous menitirftne in prcwerved. 



Fi«. 176. — Ondwwiiigonihe 
■ttlrhns which arc piirpo,«-ly 
li-rt 1uu)i. the riithi cniitiuNiHuro 
in e.vf»K<l And in it thu nutures 
are inMrtfld. 



knots should be on the oul.side of the flap so as to avoid the 
pro<luetion of little zones of mortification on the line'of union. 

'I'lie tliree .sutures hcinj; inserted, keep them long and put 
on forceps. They serve as means of traction while one operates 
the posterior li[>. The .same [irocedure is carried out on it 
(Fig. 175). 

Now iill that remains is suturing of the commi-ssures. The 
long sutui-es enable us to pull the sutured lips to the right and 
thus expose the left comuiissure. .\Iso we should trim the edges 
of the flaps so that there is no overlapjtitig and commence with 
a posterior sulun* which traverses tlie muscular tissue. The 
same procedure is carried Uirough on the other .side (Fig. 170). 




AMPUTATION OF THE CERVIX 



189 



■ In operalinj!! rapidly and under a ciiirent oF Ikpiid antiseptic 
H which an assistuiit din'ct^ in order to curry away Mouil, tlie 
H different stages can be executed without forceps or ligatures. 

■ Only exceptionally has one resort to tliese. 

I A drain is placed in the ccn'ical cavity, the stitches cut 

" short, a last irrigation is made and the parts are wiped with 

sterili/e^l ^auze while the vagina is lightly tumpunod witli 

I iodoform gauze. 
The tani]K)n is changed in four or five days; earlier if satu- 
rated with oozing blood. After ten days give vaginal injections 
»«iii(l as catgut sutures have Iwen used, that Hnishcs our openilion. 
In some cases it is necessaiy to modify the operation accord* 
itif^ to the seat and extent of the lesion. If there are some fibrous 
nodules, or some deep cysts do not hesitate lo remove them. It 
I may even l>e netvssary to groovi- rather deeply the angles of the 
luleral incisions when the tissue reaches above the vagina. 

These are the minute precautions that one is forced to take 
which fl() not complicate the operation and which avoid tlic 
production of pain. 

The results arc excellent and the niorUiHty is nil. We have 
never seen any complication. 

Indications. — -Amputation of IIk- cervix is suited lo supra- 
^'u^inal hyi»cr trophies, lo cystic degenerations, to hirge inflamed 
sclerosed cervices. It is also u.scful in supravaginal hypertrophy. 
"» cases of prolapse; in the last case it is well to separate the 
■^ladder high up and then excise the cervix freely. The suture 
*»'" the vaginal mucous membrane to the anterior lip of the 
'^tn-ix helps lowarrl the lifting up of the bladder. 
B_ .\s in a general way the lesions in these eases arc most nukrked 
* ** the intra cepiical mucous membrane, this must also be resected 
'^igh up ami it is <)uite <-on)pre)iensible that one-Hap amputation 
*** superior to two-flap amputation «hich latter does not [K'rmit 
**f such a high exci.sion of the intracervical mucous membrane. 

B. Supravaginal Amputation. 

The conoid amputation of Iluguier consisted in grooving the 
Mrix by a circular incision made l>elow the insertion of the 
iginal wall and dissected upward and inward toward the cervical 





190 



OPKRATIOXS ON THE CERVIX L'TKRI 



I 



canal. Schroder subsliluted a more extensive operation which 
j>ermit.s of excision of the whole cer\'ix and even a slight exten- 
sion into Uie .surrounding uterine tissue. 

1. Amputation with Knife.— After a circular incision of the 
vaginal nnicous uicnihranc, frw Ihe cervix jinlcriorly and |m>s- 
teriorly, and anleriorlv detach the vagina by scraping the an- 
terior surface of the cen-ix with the nail or blunt scissors. This 
separation is at lirst difHcuIt but becomes easier when tlie 
insertion of the vagina above ha.s licen (wissed. Al>nve Iliis U 
to be found a cellular stratum, in ter-utero- vesical, which sepa- 
rates easily.. On reaching the uterine isthmus desist from the 
separation as the periloneiiin may be o|>ened. 

Posteriorly the vagina is separated from the paslerior surface 
of the cervix. As the peritoneal cul-de-.sae descends just lichind 
the vagina, it is frequently opened during this separation. 'Vh\s 
accident is of little importjtn(*e and the breach can be closed 
with a few catgut sutures. M 

The cervix is now liberated in front and behind and remains ' 
attached only laterally. Ili-re aiv insi-rled the broad ligaments 
and at this level are the numerous branches of the uterine artery, 
which must be tied in tlic tissues. To do this, pull the cer\'ix 
to the left while an assistant separates the right wall of the 
vagina with a speculum. I.sohite with the finger or grooved 
sound the vascular lamina and n'ith a blunt needle pass a suture 
3 or 4 mm. from the uterine bonier at the height of the islhmu» 
around the base of the broad ligament. When tie<l the [uirls 
are cut olF clo.se to the cervix. The same is done on the other 
side. 

'ITie isthmus is cut through with the knife, which is directetl 
from above towani the uterine cavity in such a manner as to 
groove the slump slightly toward its central part. 

All (hat now remains is to suture the vaginal to Ihe uterine 
mucous membmne. taking up en route uterine muscle lo avoid a 
virtual cavity. When finished as the wound of tlie vaginal 
mucous membrane is much more extended than the opening of 
the exciseil cervix, this nuicous membrane forms a series o 
folds which radiate from tlie cervical canal toward the vagimil 
fornices. M 

'i. Amputation with Galvano-cautery.— In .\merica. in cancer^ 



I 
I 




AMPUTATION OF THE CERVIX 



191 



uf the cervix am])Utiiti(m with a galvano-cttutcr)* is still practised. 
Uynie's' method is usually followed. A Leith forceps is Intro- 
duced into the uterine cavity and serves to draw it down. The 
<wrvix is cut through with a golvano-caulery and the uterine 

fcvity is curetted and cauterized until the stirf:n'i- is covered 

Hth a Wack eschar. 

Ijiter Byrne separates the cervix from the Madder, rectum and 
lateral attachment;; and then amjjulates with a t her mo-cautery. 

Most important is to cauterize the wound often and deeply 
as the beat's action in cancer gerin.s seems to p.\tend Iwyond the 



^^ y 






flO' 177. — SupravoKinal amputntion. Truce ol oecrlian of cervix. Point of tying 

ulcrinp nrtpry. 

Moe of cauterization. It is the greatest safeguard against a 
Wuni. 

Indications. — Supravaginal amputation of the cervix has 
wpn ahovc all employed in cases of cancer. It is to-day gener- 
'"y abandoned for more extensive operations of removal. Cer- 
tain uj-nec<tlogists, Spencer in England, advocate the igneous, 
*'' to sjjeak, amputation of the cervix, with cither a galvano- 
(.■aulejy or a theruHMrautery as Iteing more useful against a return 
"f tlie cancer than the use of the bistoury. 

'Hie great majority of surgeons limit the indications of 
^pnivagiua) amputation to certain hypertrophic elongations of 



. 'J. Bynte.A Digest o( Twpoly V^ai*' Kxpcrirnoc in thn Trraitmnntot I'UiriiicCi 
y IWnMWwaiiiterj'. Ttan». Amrr. Gyv. Sor.. I8S9. T. XIV, p. "tt, JIndtm, 
'■ XV|, p. 172. Li]in«:r. Ziir Vzatv di-r Ht^ilbnrkeit tier Carciouinii. Zeiitch. /. 
^-Grt., Stnttcan. 1D03, T. ].. p. 3lt). 



Uvriiic Cancer 




102 



OPERATIOXH ON THE CKRVIX I'TERI 



the cervix and iitorinc s<'Ierosis. In the latter case, the weight' 
of the uterus is diminished by a ^ood portion of iLs k-ngth and 
there is a secondary conlraelion of the preserved parts. 



5. Various Operations. 

We will now describe interventions carried out on the cerWx 
and whieh do not enter in any of the operations we have desrril)e«L 

Scarification of the Cervix, — In m^-i erf rndoccrvicilis. when- llic finjtT 
fpcis in Uif (lilalcd cervix litUc gr»niila(iuDi>. D(»l<'ris advise.t Iho sea ri fit's tjoa 
of Uie miiroii!> inciiilirtint- w-itli « ^ciinfii-r with ntuhi|ik- nnci |>urHllf1 l)ln(l<'«. of 
whit-h UiP kngth of 3 to 4 inni. is calculatnl to penetrate ju.it to the gUndular 
rul-dc-siic* witlicnit f)ftcri<liii^ beyond llif limits of th«' niiicouH inrnil)rmn*. 
Tills swiri lie r is apjilittl jirogrcMivfiv jmrttllcl to the «xis of tiw ivrvis dilated 
to its maxiitium. The moNt voluminous cv»tic- in'aiiulntions aiv thus <>|>(*nr(l 
nnJ the smaller cut lo pieces. When the niucout inemlirane is f^'nemlly 
incised with no s\iin-*- iK-twet-ii tlie incisions then the mucous tnemljrnne is 
removed with » little curette. This operation when terminnletl leaves a 
smooth and united surface instead of the cut up mucous mcmhrane wliieh M 
exi.^ted Itffore. Lavage with $iubliinate and tamponinf; with ioiiofrinu gaur^ 
saturated with cHrljoli/wl glycerine 23 jier cent, or Sll per cent, io^lixed 
glycerine complete the operation. 

Bouilly's Operation. — In recent limited cervical metrilln. Botiilly's 
operation nniy be tried. It coii.tusLH in excising from each Up a flap, at the 
same time preserving the commissures. The lip Ijeing seized by its free 
border with a tooth foreeps, the bi.s(oury is inserted into tlie cervical cavity 
within the left commiwurc and the incision directed anlcriorty toward (he 
anterior lip penetrates into the tisxiie <rf tbe cervix to Ibe n'ljiiired ih-ptli; it 
is carried toward (he right and passes transvcrselv between the mucous mem- 
hrane of the vaginal sur'ace of (he cervix mid (br lo(>(b f<ir<'ep> and then 
before reaching the riglit commissure, it is brought back toward tbe cervical 
cavity. With u scissors one ciitt fn>m the sul^tance of this cavity the luise 
of the flap Uius traced. .\ similar flap is excised from the posterior Up. 

. (^ich lip is thus groove<J in the cervical eniial. Preserving a band of 
mucous membrane at the level of each commissure suffices to prc*"cnl the 
coaoreutive ntresia. ■ 

As a dressiiif;, Bouilly introduced into the cervical cavity some iodoform 
gauze, isalurated willi earbolized glycerine. 

Pouey's OperatioD.' — Thin conju^ts of a circular resection of all the 
internal part of the cervix. As a preliminary dilate with Ilcgar'* dilator* 

• P, Petit, Prt4»t miditaU, Pmris, 1901. p. 238. 



I 




IS4 



OPERATIONS OX THE CKItVIX UTIilil 



flfxion. |t1iiMli<r «j>iTatiim» Iiave hf^n siilHtiluted. !a Dudley's' o|tpration. 
which is particularly wscrvcd for untcflvxion. the (lustcriur lip of Uic cervix 
is split in the ni(-dii<n line with .tciMMors, aad then the intracervical mucous 





Flo. 18t.— PartSaJ exoiiioii of Uie 
anterior li|), savini; tlio intnuMirvicnl 
mucoUN mnmliraiip. 



Fia. 183.— Op^rntinndniiilici). The 
ext«riuj OS U «iitiu'geii and carriii) 
biickward. 




Flu. 183. — I'nrtinI Dxeioion of posterior Kp; when sutureii arc tied the uterus is con«ct«d 

□lembrRiir is sutured to the viigiital miirouK iiifinhninv on each of the lijis 
of the in<-i.-iion and at the level of Us superior an^le, and this n^sult.s in Uic 
rxlrrnal os heing carried wry far buck {Figs. 170 and 180). The anterior 
lip is partially excised while the external os is preserved. This hut excision 
docs away with the liypcrtniphy of th« anterior lip so habitual in anteflexion 
(Figs. 181 and ISJj. 

■ E. C. Dudley. A Plastic Op<>ratlon Deigned to StraigliUin tlie AatoHuxoiJ Uterus. 
Amrr.J. of Obttetr.. Xcw York, 1891, p. 142. 




OPERATIONS OM THE CERVIX AND PHEGNANCY 



195 



I 



Rccd' cndcjivors to coiintpract HnU'flvxroii by an oppratioii on tlir cervix. 
He innkfii, lik« l>uii)<-v, a vortical raeiliaii incision in the poNtcrior li|> nf t)i« 
cervix and cscisch from i-ach cdg«- of the incision a crcsccnt-shapod area of 
ti.viut!. This exci.tion cxt<'nds the whol« Icn^lii of tlic Inci.iion. hiil pre.terves 
tlic intraccrviciil mucous nictnbrHnc. Suturing the superior and inferior 
parbt <)f the excised areas toj^tlicr, tlie liuiiy of tin- ut<.Ti]:« !m drawn up and 
back and this corrects the cervical cunal (Fig. 183), 

By hi* o|iiT»lion Nourse,' on the contrary, rKnn-dics at will ante- and 
ret rotlex ions. He splits the cervix laterally juat to the angle of ilcxion in such 
t manner »» to completely .separate the anterinr lip from the puitterior lip of 
the cervix and to be able to make them ylidc. so to .ipeak, on each other; then. 
after hysterectomy, aided by traction on the posterior lip of llie cervix, he 
corroctH the flexion. Having done this, he now places forceps on each lip, 
holding the g>0!iterior lip thiiK corrected lower in the vagina than the 
aoteriur. A few sutures unite the edges of the lateral incision of the 
cervix ami fix definitely the lips of the Kunic (Fig.i. IHi and 185). 

In connection with rrtrofirxiim, it ia the anterior lip that is caused to 
descend lower into the vagina than the |K>iiterior. 





Flo. 184— Sketch ot ihe 
UtcTol ■plitling of thv oarvix. 



Fio. 185, — The purtrriof lip ha« 
bMD drawn into ihi^ vntcinii aad 
tilua liai oorr«otc(l thu utcruit and 
it hail then been lixeii in iu now 
retutiuiiB. 



6. Operations on the Cervix and Pregnancy. 

Do o|>eraUons on the cervix infltioiict! j)rcgiianey favorably 
or unfavorably ? We must solve these questions. 

It is certain thai some favor loiiccptiun in <ti>iiig away with 
a sterility and enabUnj; a prefjnancy tu proceed nornially, Such 
opcraliun.s as enlarfjing a .sttMuwed eervieal orifice or curing a 
rebellious endometritis. In these o[M*rations it is not doubtful. 

What is the position in operations in which a more or less 

' Cluulc* .\. ttccd. The SurRiRAl Trc^ntmcnt ol Antcrjnr DiiiplsRemciil'i of the Utorua. 
lUdtm. ISW. T. l„ (•■ '■■*■ 

' i'. p. .VouPHS An Uriginal Operntiou [or Ihe KmlitiiU Cure of Ulc-riuc Flexions. 
thidtm, l»Oe, T. I. p. 60. 




l»)6 OPERATIONS OX THE CERVIX UTERI 

extentieti excision has occurred ? This is a much discussed 
point. 

()l>servatioiis on abortion and accouchement before term, on 
rifriilities of the os leading to the death of the fetus, necessi- 
latinji baxiotriiiHy or even leading to a uterine rupture, have 
Ut'U published l»y accoucheurs' (Pinard, Champetier, Porak, 
lA'pajie, etc.). 

AudelHTt* collet-ted observations from sixteen women having 
hail amputation of the cervix. There were twenty-two preg- 
nancitvs: Hve accouchements at full term, nine before term (at 
t». 7. T 1 li, 8. 8 l/i months) and ten abortions (from the first 
to tiflh month); ten times he observed premature rujjture of the 
membranes. These women had had before operation twenty-two 
prejiuancies at term, two at eight months, one at seven months, 
and two alKirlions. The duration of the gestation appeared to 
hint to Ih' in inverse relation to the height at which the cervix 
had Ihhmi cut Ihnmgh and the extent of substance lost. 

These oKservations would appear to lead to the idea that 
amputations of the cervix have a bad influence on pregnancy 
iiiul one ought therefore as much as possible to avoid them. 
Tiv our iilcH this is exaggerated. Consider an important point. 
If the uterus wa.-; ojK'rated on, it was necessary on account of 
wlerous lesions, which of them.selves, outside all surgical inter- 
\ontK>n. might tie the cause of complications. Moreover, when 
.u-c*'uv lie Hi's' obsiTvaliotis are studied, it is remarked that the os 
\\;tx xiinitundtHi by a zone of cicatricial tissue which was the 
ix-.tiill of an incuniplcte union of the line of sutures, or an 
^.ivi.itiw iault. In certain cases the fault was more j)ro- 
lti>tllt^^^l aiul at the moment of accouchement, silkworm-gut 
vuliiu-.x base Uh'U found in the cervix, forgotten by the surgeon. 
I' ;u nv^iHvt of olwervaliims made by accoucheurs who Uavc- 
s.vii xhuvk bv such accidents one com()ares the statistics of" 
IV-^cit-*. It^'tiilb and ourselves, the results are quite ditferent. 
\> vv'l-»»" vrtM'>* Tilcrilc women have liecome pregnant after— 

iva.^tiv'i'* v'l' the ivrvix. Wc can cite the case of a womai^ 
vv>,» Vul Hv'wi- had fhildM-n and after amputation had three- 

,.>,»,''V*' MlVvVvxlUllv- 

^., .^i^,. • 'V ■*«'--<vlt I'f i>t»li'lni'h, ( !yii('C<)lc>g\' and Pediatrics, Puii. 1899. 
■••■■■■■* ^ J ^ ,j di'itiiiHu-v and Ai'ciiiichi'iiienl after Amputation of the Cer>i]C- - 



J /.-t- 



Siv".. lv»v I I. (. Jii 



OPERATIONS OS THE CKKVIX AND PREGNANCY 197 

In short, these comphcations we have considered are more 
often the result of badly done operations, of a defective operative 
technic, or an insufficient asepsis. 

It is necessary, to avoid trouble, to have the new orifice wide 
and to remain widely open, and a primary union of sutures, 
avoiding any virtual cavity in which secondary secretions might 
collect. 

Executed well, amputation of the cervix cures without 
cicatricial contraction and exercises no bad influence on the course 
of pregnancy. It is also of benefit in gestation where the vaginal 
iwrtion of the cervix is excessively long. Operate it before the 
fifth month and give morphia immediately after the operation 
to avoid the uterine contractions which might lead to abortion.^ 

' PolocLi, Amputation of the Cervix durinR Pregnancy in the Treatment of Hyper- 
trophic Elongation of the Vaginal Porticn. AiiniileH of Cyn.. Paris, 1906, p. T(JU. 



CHAPTER V. 

LIGATURE OF UTERINE ARTERIES BY VAGINAL ROUTE. 
Summary. — General anatomy. — Operative technic. — Indications. 

1. Anatomical Kotions. 

The uterine artery' is included in the hypogastric sheath, 
which envelops also some vessels which run to the uterus and to 
the vagina and also others going to the bladder and ureter. 




Ott. 



Fio. ISfl.^Uterine arterv (poBterior view). The uterine artery (J. u<.) gives off 
ome loDg cervico-vaginal oranchea. A. m. or., utero-ovarian artery; Ur., ureter; 
0. hyp., remains of the hypogastric aheath coDt&iniog the uterine artery and numerous 
veins; L. ul., utero-sacral hgament. 

This fibrous and resistant sheath extends from the wall of 
the excavation, where it rises between the ilio-pubic line and the 
spine of the ischium by a narrow root and spreads out along the 

' Fredet, Vascular Pedicles of the Uterus. Ann. de Gyn., Paris, 1S99, T. L, p. 3Q5. 

198 



ANATOMICAL NOTIONS 



199 



leiijrt.li "f llu' uterus and vagina. It is at tlie same time a vas- 
cular sheath, and a powerful means of fixation (k-scrilMKl by Uie 
Germans under the name of the cardinal ligament. At a fair 
dUtance from the uterus it splits into two layers, the posterior 
of whi<'h is attached to the lateral parts of tlie tilcnis and vagina 
while the anlt-rior gtK'S to the bladder and terminal part of the 
i«rler. It is in this latter part that the ureter is to be found 




f ici 18". -I.i)OH»irp of 'tip yasculdr uterine pt^diclc llinmEh thf viuunn. Thi' iitortv 
lAciiol pi-'liclr "Pro from behind rnvdopi-s {(1, hyp.) ; nUo the hypti((ji«iric vo"?*!!! utid 
lh«ir |i.rfWrii>r exlra-pi-lvic bratii:!ip» ill.p.fjl.p.) wlikh tormiiisti' nt the- bonlrr ■>( l.hfr 
uUmii and vngina. Tlie iitcriii*! arU'rv (A.'il.) t-iiti-ni the aheuth from itn poiiil of 
nriicin, ((.''.'(. Hrotir; <r). vaftiiin: (Cf.ui.), rnaciitnr titrrinpnyicnth ; (O.t'a^-), purtiou of Ihe 

Cilde which K<w to Ih* vagina; (B.), Kclum iieparftlod froiu tlie raginuand pmnwid 
•ii; (Cr.), vnculur. 






r |iassing under the uterine arterv. As a result of this arrange- 
ment it is possible on o[H*iiiii^ the anterior and posterior fornices 
of the vagina to isolate tlie two sides of the utero-va^irial lamina. 
Ob opening the lateral fornix the jiart of this lamina atUiched 
lo the vagina has to be separated eontaining as it ilues the 
vaginal vessels from the portion adherent to the uterus in which 




200 LIGATURE OF UTERINE ARTKHIES BY VAGINAL ROUTE 

arc toiiiiil I lie uU'riiie vessels. WIu-ii <-ul Ihroti^li safjitlally 
the utfrine portion of the vascular pedicle lias the form of a 
triangle with apex a hove and base liehnv (Kretlet). 

4. Operative Technic. 

Commence by a circular incision thronj;li the vajtinul mucous 
membrane around the cervix, and then to this incision add two 
hiteral inci.sions \vlii<-li arc proloiijied on to tlic Intend surfaces of 
ihe va*;ina. Separate uti' the vaginal inucons membrane and 
then tlie liladth'r from the cervix. ProtTcd in the same manner 
posteriorly, scrapinj^ tlie uterine tissue witli the nail. Tliis 
anterior and posterior frecinf^ of the t-ervix eiiahles us to isolate 
more easily tliroui,di the lateral incisions tlie uterine portion of 
the vascular pedicle (Fijj. 187). 

To the right and lefl of the cervi.\ tlius freed, cut through 
the fibrous tissues subjacent to the mucous iiiend»raiie at a 
height of 1 cm. If this sertion involves a branch of the uterine 
artcr^'. put forceps on it nnd lie it. Then, inserting a speculum 
against the vaginal wall on the side we operate and. <irawing 
the cervix toward the opposite side, the uterine pedicle is ex- 
posed. Ft should be denuded upon Iiotli faces for a distanct* 
of several centimeters. Il is easy to determine if one lias 
overshot the uterine pedicle by the fact that the two index- 
fingers, plac*?<l one in front and one bi^-lihid. arc only sejMirated 
above by a ver\' fine layer of cellular tissue. 

Nothing is simpler than to liook u|i the uterine pedicle with 
the finger and to draw it down and tie it strongly %vith silk 
which is passc<l on a blunt needle. 

The two ligatures having been applied, close the vaginal 
incision with catgut sutures. 'I'he drc.s.sing is an imloform 
gauze in tlie vagina. 

In o)>eniling thus, one does away with the great part of the 
uterine blood supply, tlie principal artery being lied and the 
circular incision in llie vagina cuts off the anastomotic c-onnec- 
tions between the strictly si«'aking vagiinil arteries and col- 
lateral branches and the uterine artery (long cervieo-vaginal 
arteries, vesical arteries, etc.). 




INDICATIONS 201 



3. Indications. 



These atrophy-producing ligatures were devised in eases of 
bleeding fibromata of small or medium size. Combined with 
removal of little polyps during curetting they have given some 
^(kkI results. We have in some cases had recourse to it.' To- 
day, when large operations are much simpler, we believe they 
may f>e abandoned. However, we possess a means of resource 
in hemorrhagic fibromata where, for some reason or other, we do 
not wish to remove the tumor. 

' H&rtin»nn and Fredet, Ligatures to Procure Atrophy oS the Uterus. Ann. de Gyn., 
IX98. T. L., pp. 110 and 306. 



CHAPTER VT. 

REMOVAL OF FIBROMATA BY THE VAGINAL ROUTE. 

Summary. — lU-moviil nf fibrous [>oK[ti and fibromata of the cervix. — 
Trans vagi no- uterine myomeotum y (creation of it nicranx of access, exploni- 
lion of the uterine cavity, rvacnation of fibroma, treatment of the cavity 
remaining, after ojierative tn-atrneat, itifiic«tions).—Tr«n.«i vaginal niyo- 
mectoniv. 

TliP Iwnigii nature of uterinp fibroinatH iiinitsoftcn their simple 
encapsulation, in a ctTtain nuuilxr of diseases tlie operation c:in 
be limited to tlic removal of the tiinior. whieh is often enough 
done by the vajflnal route. 

i . Removal of Fibrous Polyps. 
In ca^M oF simple fibrous jxtlyps sitimled on the cervix or 




Flo, I8S.— Mumux'h traction forcep*. 

eoining out from the interior of the cervix into the vagina, the 
o|jeralion is very simple. 

Anesthesia is unnecessary. 

w 

Seize the polyp with a stronfj traction forceps and make 
torsion until the pedicle l)reaks. [f the polyp is in the cavity, 
it is often neccssiiry to dilate the cervix, as a preliminary, with 
laminaria tents. This is rendered unnecessary generally an the 
tumor itself has [iroduced the dilalaliou. Seizing the cervix with 
a traction force[)s in onler to drag it down to the vulva, and 
then make torsion on the polyj* and remove it as staled above. 

202 




KKMOVAL OK Cli«VICAI, FIBROMATA 



20S 



I 



I 



There is no hemorrhajie to fear and if some oozinfi^ takes 
pia<"e tlie llicrmo-caulerv or ioilofonii ^aiize .siiffii'*- to stop il. 

If the poiyp is larjje so that its pedicle enierjjes from beyond 
the OS, we must think of a uterine inversion and not attempt to 
remove it by torsion. It is even iinprmh-nt to section across, 
there and then, that portion whicli appears to be the fibroma 
pedide. One is cx[H>sed to the duiijtrer of eiittiiij; into uterine 
tissue and opening the [leritoneal cavity through the inverted 
uterus. If a vohintary and methodical openinjj of tlie jH'rit- 
oueum is regarded, strictly speaking, as anodyne, one cannot 
say the .same of the invohnttary and perha]>s ignorant o[K'ning 
of llie ojierator. We must, therefore, avoid this accident. 

It is done in the foUowing manner: Apply two traction 
forcejw to the fibroma near its free extremity and at Iwo .sym- 
metrical points l>cginning at its extremity and spHt it in the 
median Hne. The foreejis are then removed and fixed on llic 
two lips of the incision in the fiitroma, causing it to gape. Then 
pro<'erd with the section until one comes to the hir)se caji- 
sulur tissue which is met with at the base of implantation of 
tlie tumor. Nothing is simpler than la raise np separately 
the Iwo halves of the fibroma without risk of uterine perfora- 
tion and thus shell llicm out of their capsule. 

For ifiiinl l'i>lyi>t accompanied by gangn-ne. removing them 
in pieces is necessary. Conmience at the center and go toward 
the [leriphery, advance gradually and terminati? by extirpation of 
the pedicle. The preliminary disinfection by antiseptic injec- 
tions for several days following is useless. It would lie, in any 
case, ilhwory. for it is impossible to disinfect the tissue of the 



tumor. 



2. Removal of Cervical Fibromata. 



telve find a fibwma included in (he lips of the cervix, the 
if uterine tissue around is freely incised, including even the 
la: then with traction force[)s seize Ihe tumor between the 

two lips of the incision which encroach upon it. Draw it out 
while «-ith the nail or a blunt instrument free it from its cafwule. 
In rare cases of difjuxe fibromattt of the cmns:, we must do a 
supravaginal amputation. 




204 



REMOVAL OK FIBROMATA BY THE VA«1NAL RtitTE 



3. Transvagino -uterine Myomectomy. 

Devised hy Velpeau and [>riictiscd bvAniussat. eiiucleation 
ttf suhinucniis or interstitial til)r()ni]ita Ity llie vaginal mute only 
l>e('nTne jieneral sinrc tlit- |iii)>licatjuii of result.s Ity I'ean. Seyond. 
and Doyen, wlio have conibined with [ireliiniiiary hyslercf-loniy 
the breaking up and enneleation of fihronialu.' f 

I. Preliminary Creation of Means of Access. -I'm- little 
tiiinoi's, ttilitU' first triUi hiniiimria; generally one has reeonr?* 
to hyittcrolomy. 

Doyen advi.sed antcni-nieelian hy.stenitoniy which in done 
aa follows: 

After incision of one-half the vaginal eirenniferenee, free Ihei 



/^ 



ft 



■^7 

-fi: 



■111. 



KlO. 189, — Aiit"T<i.iii(Hli»ii liy>lvruU>iiiy, Two (orcc-fiH fix Uie cervix lind \.wa aX\^ * 
droc down unrl M?|Mirati- thp lip* o( tlir hyuti-TntiMtiy iocUiiia. i,l>(>y»n.) 

anterior surface of the cervix and the inferior part of the uteri -^ 
Se|)arate up the vtigiiiii at first, which is a little [Ntinful. and th^^ 
the Iilaihlcr. This Is easy i)wing to a layer of cellular aie^^ 
lamellar tissue l>elwcen it «nd the uterus- -a layer which |>erin^^ 
e]isy cleavage. If one considers the st>[Hiration high cnouic^! ' 
place a speculum iR'tween the |Mtrts which so retains Ihe^^ 
Then dniw ^iown an<l fix the ecnix with two traction forevps L ' 

' ^*v on lhl« (jtM«tian lli« imporUMit monoRMiiti of Purli&uc*. CanMTv*liv« 8ui 
o( Ilie ITlenut kd(I .\<lnexs in FibnitiiAiit Th. tU farit. I1MI0-IW1. So. 385. 




TRANS VAGIX0-UTERIN1-: MVuMFftOMV 



205 



le<I into Iheiinteriorlip. Split in the medinii line tlic cervix antl 
uterus, and tlicn si>i/.o tlic lips of tiic incision with forcc|ks hiuI 
proceed in Uie same way as that we Iiave described at greater 
[length iin<ler vtujuml hijHierectnmtj. 




Via. ino.— StiKnnil'K S-Hbapc<i «p<!culum. 



TIk'.sc force]>s serve to draw ilowii the uterus and also to sepa- 
rate tlie lips of the incision. Wlicn t)ie uterine cavity iswidcly 
"pen, wc* ean attack tlic filironia (Fif(. 189). 




Fid. 101. — miatrrkl hrxlmilomy. The icctinn U hitihc-r iiitPtniilly thnn L>xt«rnAl1y. 

Pean an«l Segond iwrfonn a uni- or bilateral splitting of the 
cervix to Uie antero-niedian Iiystcrotoniy, 

The [xalieiit lieing in the dorso-sacral po-sition. the assistant 
to lilt' right lifts up the anterior vaj^inal wall with an S-sha|KHl 




Pia. 193, — t'lillutiTsI i>|iliiIiiiK «( th* cottIx; odd can see tJie llliromk eorored I 
with nlvrino muooua nirinliruir whiuli luui Immid «iiened by Uio nuL (S«|oad 
UurtigUM ) 

strong blunt scissors, we introduce one blade into tlie ccrvif 
uterine <ranal anti llie other iiil" the eorn>s{jon(iiiig fornix. ^ 
tlintugh eiicli commissure up to the istlimus, encroaching 
the lateral Fornix of the vagina. 




TRANSVAUINO-irrERIXF, MYOMECTOMY 



207 



If, after lliis dnulih' (•crvici>-vHf;inul scctum, access lo Uie 
cavitj' is still difHcult, Sefrond advises to continue the incision 
hif^hcr, taking care not to go llirough the whole thickness of 
the uterine border, but carrying the section liigher on the internal 
ft surface than on the external in order to avoid injuring the 
uterine arter)-. Tlie iiidcx-fingcr may conijilcte the enlargement 

(>y separation. 
Inversely we sometimes only do a unilateral cervico-vaffUiai 
II- 



i 



'WH 



Fig. 193. — Scgond'i corkwiretr. 



hy-ilfrotom^. We should limit ourselves to what is strictly 
necessary. It may. however, Im- necessary to do the bilateral 
section. 

i. Exploration of the Uterine Cavity. — It is useless if the 
fihmma presents after splitting of the cervix; when the tumor is 
deeiter, we nmy explore the uterine cavity witli the index-finger 
so as to find tlie exact scat of the fibroma and where it is most 



Fio. IM.^IjimOKtUtfxl kaitv for miirncllcmi^nt of (ibroDuta. 

accessible. To do this remove the s]>ecula and draw down the 
uterus witli forceps which fix the lips of the cervix, luring aided by 
the intrauterine palpation of the hy]»ogastric hand which presses 
on the fnndiiK of the orgaii. 

3. Breaking up of the Fibroma.^When the cavity is ex- 
plored, the index-finger is place*! in the most accessible |>art of 
tlie fibroma, and one tries to break through the [H.*ri fibroma tons 
shell with the finger-nail. Sometimes it is possible to imrae- 





208 



lit:MOVAL, OP riBROMATA BY TtlF VAOIS'AI. ROITTE 



dintoly einiclpjite tlie filtroma but. rero^iiizwl liy its Miitic^ 
aspect, protnuU-s like a lu-rnia tictwi-eii lips of the muscuU 
mucous membranous nount). In other cases, it suffices 
dniw down the fibroma, with strong Museux's forceps, or muv b 
by a corkscrew as Sej;oiHl docs. Il is well lo coinliinc Museux's' 
force[)s with I he (■orks<'rew, 'Hie forceps draws down llu- 
fibnmm into view. Il is easy now to insert the corkscrew without 
relinquishing the other. If the fibroma is small, enucleate it^ 



A 



Khi. IVi.— Hw dotted lino indintc* the tnoMoit landc by the knl/« to «iii Uw blmm 

■one. 

if hir)^'. Iiix'uk it up. This latter is earned out willi the xpiruU ofl 
(he cnrkttcD'W as axis and bnse of support. It should Im' iin* 
phirittMl firnily. but not too well to pn>venl the moveincid of th^ 
knife. The left haiul draws on il gently nnd the right take?* 
Hi'gond's knife, which we will desfTiiie. This instrument has 
H long htindle and a slightly curved doublc-ei)ge<l Iniiceolated 
liliidi<. Il is in.s4Tted into the fibroma and directed ot>li(|uelT| 
ttiwiiril the extivmity of the c-orkscrew. until its |K)int just lies 
Im'Imm il. 'I'hen witli gentle movements from side lo side, make 




210 



REMOVAL OF FIBROMATA BY THE VAGINAL ROUTE 



act as s{K'Cula. It i.s UM'tcss tit make use of tlii^ inferior spcciiluii) 
which serves to lower the perineum. 

We liave inentioiu'd not to force the corkscrew in too much; 
Ihis precaution serves to facilitate tlie movement of the knife. 
If il is too deeply prt'sscd in, it is difficult to circle around its 
point nnd it jjets entangled witli the corkscrew spirals (Figs. 195 
and I9(i). 

When the scooping out is advanced sufficiently so tliat the 
line of capsular cleavage is found we can. with the finger, 
produce movements of torsion and traction comliined, and thus 
produce the freeing of the superior portion of the tumor which 
comes into the vulva "eii bloc.'' In other ca.ses we are forced 





Fifi. 107. — Losfngo morerllpmi'nt. Fia. 198, — t-adder or F,cheUe morccl lenient. 



to go on slowly till the hitter en<l. Prudence suggests, however, 
suhstilutiiig the corkscrew for force(>s and ttluiit scissors in order 
to finish this last morcdlcment. We must also make many 
digital explorations in such a way as to appreciate the diflcrent 
consistence of the fibroma and uterine muscle and at the same 
lime to learn the thickness of the wall of (ihrous tissue capsule. 

In absence of special instruments, the morcellement may be 
done with traction force|>s and scissors. 

It suffices to seize with forceps a part of the neighboring 
fibroma, which one desirt's to remove, in such a manner as 




TRANS VACiINO-UTERINE MYOMECTOMY 



211 



nol lo lose hold and to bring to the exterior of the wound a part 
oftlie filiroma. 

The lozenge morcelicment and the shell variety, which Doyen 
has so well descrilM-d, art* useful in the scooping out of tlie center 
of the fibroma. 

All these manipulations do not hring on a notable hemorrhage. 

'I'he morocllement is usually dry. The shdl having been emptied, 

the uterus retracts on itself and bleeds very slightly. 

[ 4. Treatment of the Sites Occupied by the Tumors and of the 

XJterine Cavity. — After being assured that the uterus has not been 




I 



Fio. 190. — Rtntilt of "luddor" or tCchnllc moraollompnt (after Uoyen). 

(Hjrforated, see if there is any heniorrhiige. T'his may cerise 
■Spontaneously on retraction of tlie uterus. If not, apply force|>s 
<*»» bleeding points. 

Hemastasis l)ping secured, do the postoperative toilet, excising 
'i^gular and floating flaps, removing the dots and doing a hot 
••itiseptic irrigation. 

Dr^" the parts and tamp oii the cavity of enucleation, as also 
t^»< uterus, with gauze wirks, one extremity of which is left in 
^c vagina so »s not to Xv forgotten and left in Uie uterus. 

5. Suture of the Cervix. — ^This suture is not always indicated. 
It may be done if the uterus has Inren largely split or when tlicre 




212 



RKMOVAI. OF rnmOMATA BV THK VACINAL ROUTE 



is a hemorrhage at the level of one of the lips of the incision; 
on the contrary, it is net*ess«ry to abstain from making any union 
wlieii the incision is not deep and does not bleed and, above all. if 
one has Ijeen obliged to U-ave one or more forecps on the vessels 
in tlio interior of tlie old tumor cavity. 

After-treatment. — -'I'lie lirsl dressing is nia<le from the sixth to 
tunth day. unless infectious process oblige an early i-emoval of the 
intrauterine drains. 

The drains having been removed, we can make a hot intra- 
uterine irrigation, at 45** C, dry the cavity and tampon after- 
ward lii;htly. 

Indications. — \"aginal removal by morcellenient of fibromata 
is indicated in cases where the external face of tlic organ lias pre- 
stmted a ri'giilar form or where the uterus has remained mobile 
and where nothing causes us to susp«'ct the existence of accom- 
panying lesions of the udnexa. 



4. Transvaginal Myomectomy. 

In trans vaginal myovLectomks the route chosen is the vaginal." 
Colpotomy anterior,' without incision of the peritoneum, suits 
onlv the removal of little fibromata which arc situated low down; 
the posterior'' to retro-cervical fibromata having split the r'ecto- 
voginal septum; the lateral* to small intraligamentous fibromata, 
above all to thosi? which have a limited insertion into the border 
of the uterus. 

In all cases, aftt-r reaching the fibroma ennclenle it, with or 
without morccliement. according to the case, carrying out a 
procedure analogous to that of intrauterine myomectomy 
which we have so lengthily described. 

' \Vt! duul here (iiilv with operatiuiiB wltprv l\\vtv is no opeuiiig of Uie pori Ion till 
OUl-d^sitM- Wc (leal filter under colpo-wliot^nny with thn cnorH where the periUinciira 
is OpUDl'li. 

* D'lIrrWcaurt.'nieVtigiiialltuuto without Hysterectomy. Th.de Paria,l90f>-Wi\ . 
' Ott (n. de), Thirteenth Inlcrnntionul (^ongrcai of Medicine, Puru, IWD. Cynoooloi- 
ica) S«oti(in. 

'StrnW. J.iitiTul Colpotomy. Cenlr..Bl./. G,«n., Lvipiig, 1890, p. HOC. 




CH:U»Ti:U MI. 



COLPOTOMIES. 



Suminary. — Posterior cofpofoniy (operation rr^ults, indioHtioDK; fixing 
linilcni* ill the VAgiRa witli tint fiiiuluslK']i>\v;shiirlctiiiigDf thcuteru-^acral 
li|kin«iits; treatment of uterine inversion). — Anterior colpotomy {o|»Tnlic>n 
tiirxiilientionit of tt-chnic nrcordiiig t" the ease; opening of aliscfiss. explora- 
tion, remoral of tumors, correction of uterus, fixing ulcrus in vagiiiii willi 
fundus briow. resiill;), indicnlioiis). 

Taken in its most comprehensive .sense, mlpotomtj signifies 
incision of tlie vagina. In practice we limit the word to Inci-sions 
limited to the vagina, adding to it a (qualifying word if any olher 
orpin is implicated in the i>]>pralion: for example, ne talk of 
colpocystotomy when we refer to the opening of the Iilaiidcr 
tlirough the vagina. 

The fundus of the vagina is occupied by tlie uterus, with its 
lirond ligaments enclosing the va.scular pedicles; an incision into 
thps*' lateral apiK-ndages is never made but colpotomy i.s cither 
practised in front or behind the uterus and we get the distinction 
Uius of anterior col-palomy and posterior colpotomy. 



I. Posterior Colpotomy. 

Generally posterior cuIi>olomy is not limited to the vaginal 
*al|. As the posterior vaginal wall is doubled by the peritnneai 
recto-uterine cul-de-sac, tins is also diK-iicd, hence in it-ality a 
iHwlcrior coip(i-€clioinmif is practised. 

Operation.^.'MI prvliminar}' precautions to vaginal opcnitii>ns 
j.^ving been taken, a brood short sjteculum is placed on the 
posl<'rior vaginal wall, depressing and drawing down the four- 
cV'lte with it. Seize tlie posterior lip of the cervix with traction 
fmTe|>s and draw down the cervix and lift it strongly forward. 
"Hiis manipulation results in stretching the posterior fornix 
*bieh is well drawn back by the vaginsd speculum. The in- 
tiiiion is mode with tlie scalpel. In no case is it perinitte<) to 

213 




214 



COLPOTOMIliS 



employ the trncnr in »i|)itc of tlio ar^iiiiK'nbi of the Lyons school 
and several German Kynecolofjisis in favor of this iiLstruincnl.' 
We du4countenaiu'c ils fiii[»iriy i«'faiise it is bhint and may injure 
Ihe rectum, sometimes united with the posterior fornix. There- 
fore the scalpel is useil to ini'i-se the vaginal wall. A trans — 



Via. 300. — Poitcrior colpolomy. A (peoulum iJmwh down tito pcnt«riar wall of tb« 
voeBA uid n pMT of r»n-i>|w ilmwa tli« cervix (nrward. The do(l«d Udo KftfcaraUDN 
(n«won in the niueoiM iiK-'iiibrune of the vsKiiin rvrtiiitMl in tlve oorvis. 

vcnic incision euLs Uirough the vaginal wall and even encroachfs 
on the cervix which serves as a sort of executioner's block. How- 
ever tempted one may Ih- to incise the pnnnincnce of tlic posterior 
vaginal wall, it must not l>e done. 

' Rpreciily Fnu.-nkc1 iwlvoFiktotl puocturv Iwcntwc Ut« '<rii1|)i>l mus«» liemorrtucc luid 
&liK> lic-caUFC thi> iMjckcf ntitrimiiticiuly (tttinol bp n-iichwi fmm n distMiee. Fnenk ' 
Die vnfiinalc Inciwm, Arrh. J. Oyn.. Brrlin. 1807, T. I.XXXllI, p. 171.) So 
UlCW iilijCrliDii'. I; v.iliii 



I 




■ The vagina when incim?<I may present one wthrec asix-cta: 
I 1. A collection in the posterior fornix winch Imlpes forward. 
I a. A collection HJthonjili .situalc<l low down may not press 
I hack the dome of the vagina. 

I 3. Or the collection is situated high up, being several centi- 
I meters fr*»m llie posterior fornix of the vajjina. 
' Col|jotoiny is only a preliminary to a more complex operation 
(n^moval of adnexa. of u fibroma from the postcHur surface of 
the uterus, etc.). 

In the first case, simple incision at the posterior fornix gives 
uUDKMliate vent to the contents of the recto-uterine pouch. 

' In the s4*cond, we must M^areh for the pouch and to do so 
njust proceed in a methodical manner. The posterior wall of the 
uttsruH an tjiiide, the index-finger slowly separates off the ti.ssues and 
rotmiins in contact with the wall until it i-eaches the level of the 
collection. It is now Iwst to insinuate the finger into the angle 
wHich is formed lietween the uterus and the retro-uterine pouch. 
'fhen having penetrated Into this angle, Ijv directing the finger 
I>a€'kw«rd we burst tlie pocket and give vent In iLs issue. 

\Mien the collection is situated high up, some centimeters 
above the fornix, its localization is mort^ dltKcult. We must 
rcujeml>er that the pockets which are situated high up are 
iiiure often juxta-median than absolutely median, .\fter. there- 
fore, working in the median line of the puslerior surface of the 
uterus, one should direct the examination toward the affected side. 
Iti these cases place one hand on the alKlonien and this presses 
<iown the tissues. This hand hel|)5 to guide the pocket toward 
the index-finger. In the cuurse of the search for a suppurative 
*^o||ection. situated deeply, it sometimes ha]>|)eris that pockets 
'*f serous contents, more or less abundant, are oftened. The 
"•fiiptionof this serous fluid into the field of u|KTation should m>l 
•*.*aii one to think that the o[>eration is finished. Their existence 
•^ally confirms the existence of a subjacent suppurating pocket 
**-nd ithould lead one to go on with the search until it is found. 
»ii' careful to always keep in touch with the uterus so as to 
ftvciiil injuring a loop of intestine. 

The pocket having Ix-en opened, its contents flow out without 
•ny difficulty. There are, however, cases of old hematocele 
*here the blood in solid clots should lie evacuated with the finger 




216 



OOLPOTOMIKS 



or u blunt curetU?. One might Ik- It'inptcil to irrigate the pocket; 
we do not advise these irrigations wliieh are more dangerous than 
useful. 

Finally, the operation is finished by the insertion of a ilrain. 
We can make a s[>etial vro»s drain by running a -small one 
through a larger and fixing with a suture. This will not then 
fall out so easily. However, an ordinary drain will do if we fix it 
1o the posterior lip of the eervlx with a silkworm gut. Vaginal 
tamponing with iodoform gauze, frequently renewed if necessary, 
con,stitut.eH all tJie dn'ssing. 

Carried out as a nwatis of aceess, posterior colpotomy presents 
no U-elinieal difFieulty. When the peritoneal eul-de-.sac is 
ojK-netl. we enlarge the ineision with the finger but never sueeeeil 
in obtaining, according to Ilerbecourl, a circumference of more 
than 15 cm. (6 inches). 

Results.— /mmerftfl/c resulis of po-sterior colpotomy are excel- 
lent. The mure iliitmtl rf«ult.v vary, on the contrary, acconling 
to the case. 

When the collection LienveloiM'd in a pocket of recent forma- 
Uon (purulent discharge of the recto-uterine sac, infected 
heniato<'ele), the cure is tlie result. 

If. on the contrary, pus is Tornicd in a pre-existing cavity 
(ovarian or tuWl) recovery is often incomplete and after the 
(li-scharge of the [ms there is an amelioration of the symptom.s. 
a fall of fever and cessation of jiain and a disappearance of 
(-onipn-s.sion ,symi)toms. liut il is often a temporary ameliora- 
tion only and we have recourse to a more radical o|>eration later. 
Kven in lhe.se eases <;olpot(nny is an cxf-cllent oix'ralion, if it is 
regarded as simply palliative, so as to ameliorate their symp- 
toms and place them in inon- favorable conditions for a radical 
ojK'ration. 

Indications. — IVsterior colpotomy is principally indicated in 
anite and mibacufe localized infectiaiiji, if the examination of the 
patient permits of deternu'ning the .seat of infection. U is easy if 
Uirrc are large bulging collections in the jiosterior fornix. In 
small and highly situated collections it is more difficult. In these 
cascH the finding of a point of ex<piisite tenderness is a great 
help to the surgeon. 

Colpotomy has its indieation.s in certain hematoceles, but we 




POSTF.RlOn COI.roTOMY 



217 



must make certain distinctions. In recent licmatooeles, in process 
of evolution, when it is dilHcnlt to say if the lileeding is still going 
on or has recommenced, don't practise this oj)eration. We 
know of fatal eases of hemorrhage in spite of tamponing on the 
surgeon's part. 

In older hematocele, non-suppurative, many gynecologists 
make a vaginal incision. Even although tlic results of evacu- 
ating colpotomies are, in a general sense, undoubtedly good, 
there is an advantage, we consider, in having recourse to the 
abdominal route, which not only jx-rmils of the evacuation of 
blood, but also of treating the diseased adnexa. and thus leads 
to less chance of sccondarj' infection of tlic hemic pocket. 

On the contrari', in suppurating hematoceles, posterior col- 
potouiy is indicated. 

The posterior vaginal incision has been carried out as pre- 
timinury operation in order 1o extirpate di.sea.sed adnexa. of 
small cystic ovarian tumors, of pediculated fibroids on the pos- 
terior surface of the uterus, and in onler to take out a fetus in 
extrauterine pregnancies, etc. We prefer abdominal incision, 
however, to posterovaginal celiotomy. 

It is said tliat exploratory posterior eolpotomy should \w the 
first stage of a vaginal hysterectomy and should only follow the 
0|KTalion when the examination of the adnexa by the posterior 
route had established the legitimac}' of a radical intervention. 
In practice. It is often a bad means of exploration which may 
mislead greatly. 

lji\ us say in conclusion that posterior eolpotomy may con- 
slilute a means of drainage in tubercular peritonUis. It was used 
by Lohcin, but we do not approve of it. 



I 



Fixing of the Uterus in the Vagina with the Fundus below or 
"Bascule" of the Uterus. 

PoAtirniirc(>l|H>toiiiy Iiuk Ix-cii iilili/e<l I»y Fmiritl on first stage of an opvru- 
tJon for prolapse. It pprmita of fixing the uterus in retroflexion in the vagina 
■nd nf Hxtng il in ibi new .titiinliim. Tlni.t we epcate a tort of large va^nal 
taiD|>r>n whieh >)U]i|)orts the prolapsed vaginal walls. 

After [Kjst^rior colpntoiiiv. Fffunil "haseules" the uloru!i on the vaginn, 
ctojim up the posterior fornix, then after dentidstion of the anterior and pos- 
tenor walls of llie vagina, he scrn|ieH the tjli-rine Mirfaee.i with a curette und 




318 



COLfO-rOMIKS 



fixes it thi'ii to thf (Irnuikil voginnl Hurfncra with ralgjut &utUKs. Ho con-' 
clu<)ej the <>[>eratiii[i l>.v |>erf(>ratiiii{ tlifi fiindux i)f the ulrnix prajcc-ting into 
the vttginn. 

Shortening of the Dtero-sacr&l Lig&ment. 

After |iw(teri(>r colpotntny. paAs a suture thmiigh the utcnt-yiirnd 1ij;ii- 
meat about -t or 5 cm. from thr crrvix uteri, unti thru |>A!)t< it tltrouj^h tlte 
]i()Ltlcr!c>r siirfMoc i»f thr cervix of th*' ulcrus. Then <JniH- ihc cervix U|> iinc 
back, which will tiirn*i-l the rctm-iU-viiitiuii ifiuttsrhjtlk. Stralz). 



Fin. 201, — 'I'Uinu fixi>:l m Ihi! vnginn nftcr pnvierinr coljioCamj' aiid sutured to It 
dvaudvd AiiWrior and iiiwierior whUk, and ttien iierfumlcd nt tl» (undiw. >'ot« lti« 
fondua UuA Iwlow. 



Treatment of Uterine Inversion. 



J 



KU^tner. uflrr colfioloniy, hook-t up with his lingtr tJic tunnrl oon^tilutrd 
by the iiivcrteiJ utrrai. lie luakc^ a median vertical incision in the |i>Mlcri«r M 
surfure u|» to i cm. nbovc the eviernal cu unil rt'ihttVA Ihc invrrsioo lis un4> '■ 
Joes the Rngn of ■ }{l<ivc; then after dniwinf^ strongly u(>on the rptraflrxftl 
uterus he sutures the incision matle in the |i<isterior wall. M 

ThiH operation has been inodiliecl by Italian surgeons, Piccoli, Mnri«nni 
and Sava, who divide the renix in its entire thicktiexs and inciiie (he uterine 
wall in il.<» whole length. The iiterun is then formed, as it were, of two sltellcl 
which ar<- unilerl niileriorly. Placing the thumbs on the anterior wall which 
is |Mi<h<-<l iMK'kward. one draws forward with the other Hujjers the lips of the 
longitudinal ])osterior indsinn and thus returns the potttvrior wall. All that! 
now remains i* to xiilurc the incised posterior wall. Duret adviM-s thil 
method of operation in Kranee. 





-urii..'.' .11 Till' tiMnu OB* nuty 

(il:iI i;ii1-(Il--iiiO. 



It passes Uirouj^h the insertion of Die vagina into the utcrit 
cervix. But as the anterior colpotomy is ordinarily ilestini 
for a more complex 0[KTiition and as the surgeon ntU!it have i 
much light on his operation as possible, it is more often tlie ca 
that he is forced to combine willi the transverse incision anotb 




ANTERIOR COLPOTOMY 



221 



intero-po-stcrior iticUioti 4 or 5 cm. long. This U made on the 
anterior face of the vajjina so that we really have a T-shaped 
incision (Fig. iOi). 

The anterior incision may be veiy extensive, so that some 
operators cunBne themselvos entirely to it. 

i. Scpanilion of the Bladder. — ^This may be done w-ith the 



I'lO. 3M.— KixkUon o( tliv ul«rus lUrectly to tho va^na williout loWrposition 

of tho pcritoncuiD. 

^^*gw. It ought to be done verj' thoroughly, particularly in the 
''•ttsverse direction, and c-arric*I out until tlic vesico-uterine 
^•de-sac is reached (Fig. ^03). 

3. Opening of the I'critoneum. — 0|»en the peritoneal cul-de- 
^^ with die finger. If the colpotomy is done purely for evacua- 



222 



C0I.P0T0MIE8 



ic e a 

I anm 
itioQ ■ 
mir ■ 



lion, this motlioti presents no inconvenience, but if done as pre^^ 
limiiiary to a second operation, the o[)ening of the iK'rIlonPum ' 
should Ik.' carried out willi more precautions. We should^ 
methodically open the serous membrane which appears as a( 
floating fold of gruyisli color. First take it up with forceps and 
then incise it with scissors or bistoury. The lips of the incision J 
are iniinedialely taken up with forceps. " 

Modifications of Technic According to Case. — 1. Opening of 
a Suppurating Focu.t. — When anterior colpotoniy is done witfafl 
the object of emptying an unleuterine collection, the o[>entng of 
the peritoneum is followed by the evacuation of the contents of 
iJte jKickct and it sufHceii in concluding tlie o[)cration to plnc gja. 
drain in the site. 

2. Means of Explnratimi.^Whvn the uterus and adnexa 
fixed by ailhcsions, the finger only can give us the informatit 
we require. When tliei-e are none seize the uleru.s wJUi a \ta\ 
of bullet forceps and ilrag it into the vaginal wound; the adnexa 
thus dran-n up may i>e examined directly. 

3. Removal nj the Ailnexa or a Uterine Tumor; Ligature ofl 
the Tubes. — The removal of the adnexa presents no more] 
(Mrlicular difficulty than manipulations for their ltl>cration.l 
These difficulties, subonliriate to tlic extent of the adhesions and] 
the skill of the operator, may W great if the incision lhn)ughl 
which one works is limiteil. The freeing finished, it onlH 
remains to extir[)ate the diseased adnexa. We now proc<.*ed to* 
the heinivslHsLs following princijtles in so doing which we will 
study under the heading of removal of organs by tlie abdoinitinl 
route. 

Anterior colp<iti>niy may also be utilized in order to rrmove 
a fihriyma from the anterior wall of the uterus or an orrtrtun cyj»t.^ 
It also |)cnniLs of the evacuation of parauterine fetal cyst. \\\ 
the same route the tubes have been divided between tieo ligatures. 

4. Correction iif tlie Hetrudcviated Uterus by I'agino^fixation. — ^ 
This procedure which has been so often used is of the simpler 
character: The peritoneum is o[K-ned and the uterus anc 
adnexa arc oxplore<l. 'Iliese are freed and extirpated if ixevv- 
sar)-. Then the uterus is jiressed ilowu anteriorly into Uiel 
vaginal incision with Uie aid of bullet forcejw. It is seized near 
the fundus. Next a series of sutures is passed which jx'uetrates 



'nd 
(•♦■■ 

Ihel 





^U). 20ft, — Tin- iitsruB IB ilroiiulv lirnu'n (Inwn lriti> lln.- viijtiiiH rnnapi- of tlie 
W*M» whidi unit« IW iiiijMT wKtnoul of il- anU-rior nurfaiw lo llic [writoncal ciil-dc- 
■*"■ «lu<h U well prMvd (>nrk \it-lnrti lying this TiKUlioii »iiliirc I'lio Auliuii of the 
^■>*na«ill 1x1 tma UUi poinl iieru-MroiM. 





224 



OOLPOTOMIES 



one uf the li{>.s of IIk- va^iiml wall, tntvprsitig llio anterior vnl 
of the uterus and coining out at a symmetrical point in tJie Up 
of the opposite side. We may use i-itJuT .silkworm gut or calgul. 
The sutures .should not be tied at once. Insert them oi^d then 
attach forceps to them. When they are all in place tie themfl 
and thus dose tin- vaginal wound with wliieh the pressed-donn 
body of the uterus is in contact. It is thus fixed in a posi-j 
tion of anteflexion (Fig. 206). 

In order to avoid the formation of a cicatrix at tlie site ol 
the uterine fixation and in order to obtain .«mply a sero-serous] 




Pi<i. 2Uti. -L'tijnifi with (uiuluH boiuwat- 
t*diM in Uie vagina oTtDr antorior col- 
potomy and lixed to a donud«kl portioa of 
th* vmIoo-vakId&I spptum. 



(tiLdd ia Uie thlckoMs of ihe veaico-t^-j 
({iiiiil septum. 



fixation Duhrssen modifies the operation in the following way: 
He does an ordinary colpotomy. inserts a single fixation suture 
consisting of a larg<? silkworm-gut suture. This traverses one 
of the lips of the vertical segment of the vaginal incision near its 
upper extremity, traverses the vaginal wall, then the corrc* ■ 
spending lip of the peritoneal incision, includes Uie anterior wall 
of tlie uterus and conies out through the iH'ritoneal and vaginal 
lips of the opp<)site sitie lhu.s following a symmetrical euuntc 
(Fig. iOS). \ pair of forcejjs seizes the two extremities of the 
fixation suture, u^iirh h tii-ti al Uie end of Ute operation. 





AXTKBIOR CX>IJ'OTOMY 



■ Wf then proceed to Uic closing of tlic pcriloncal ciil-iJo-sae 

■ by a sagittal continiunis sutiirp uwl then ihe vaginal incision is 
closed. Tlie iieritoneal sulurc and the vaginal suture imgljt to W 
absolutely independent, one or the other. Nothing more re- 
mains to conclude the operation than to tighten and tie the fixa- 
tion suture. 




Flo. SOS. — Tliv ulvnif in ilruwu into 
Ih* wound <if the fnlmi'CcUntoniv. Thi- 
UibM M« tlwl ftoH tniMi cut aoiotts 
weiire (tcriliMiUiMi of Ihe palicat. 



U> 



b 



Via. 2Ufl --The ut*?ru» in "liM- 
rule" (llml ji tlir FundiiK in drawn 
dow[i Hill) th*' urKXC thu!) in- 
VLTtcilt in the vnKttiA. Tho >h 
dominfil ciLvity in clitmril liy Mitur- 
[ng lliv rt'tro-vnidul pcntoiieuni 
to tl]<! paitnior nurfaire of the 
at«-ru». vfliicli lian lieconio ante- 
rior owin^ 1(1 llif iiivvr*ii>ii of t]i« 
orjtnn. 



As dre.st>ing use a tampon af iodoform gaii/c. It', like Duhm- 
sen, silkworm guts are used to suture the vagina and fix the 
uterus, they arc rcnio%'ed on the tenth day. 

After the 0|ieration the anterior surface of tlic uterus is appHe*! 
to the serous covering of the new peritoneal cul-de-sac. U is 
then mainlnined in its new [M>sition hy pure |H>ritonen1 adhesions 

lA 



226 



COU'UTOMIES 



and tlierc is no fihroiis nodule in the eellular pre-ulerine tissue. 
By tJiis procedun- the uU-rns is antcflcxi-d and without iixing'it 
Ijglitly to the vaginal wall it is allowed a certain amount of 
mobility. Vajrino-fixaliori was advm-ated in France by Le Dentu 
and Piehevin. 

5. Fixing of tiie Uterus in the i'agina with the Fundus below or 
ifie '^ inversion" of tite Uterus. ^For the "inversion" of the uterus 




Fiu. ^lO.^TLu ulcriii is pluuisl in contoot 
witii tit* bbdd«r. Thr siitur« of tiin vn^inftl 
fl^n to oomroeDoed pooliyriorly. 




Fio. 211.^ — Tilt' sulure of Ihc va- 
^nnl wall Ik conchidiyl. having 
Pxpoaei) ti slj)(ht exMut of ut«Tui« 

lisBue, 



in Uie vagina after Freund's posterior colpotomy, Fortsch substi- 
tuted, in the treatment of prolapse, the "inversion" by an incision 
niaile in front of the errvix.' 

The uterus is fixed to the anterior wall of the vagina, from 
which an oval has been cxciswl; posteriorly it is lodge<I n a sort 
of bed formed of two little flaps cut from the right andleft of a 
T-shaped incision in the posterior vaginal wall. 



' FritMh. CftI- Bl. f^r Oyn.. IStOO. No. 2. Wtirthmm i» contnnt with fixntion to 
Miterior wftU of vaguia (Ibid., 1899, No. 14} and Bunika {ZtiUeh. fiir Grb. und Oyn., 
ISOl.T. XLV,p.<22). 




ASTKRIOR COI.POTOMY 



227 



I 



Tliis operation has the inconvenience of suppressing; com- 
plet<-ly llie vaginal ciivity. It was soon abandoned for the 
fixation of the litems in the substance of the vesioo-vaginal 
septum, thus prcM'rving a vagina useful for copulation (Watkins,' 
Wertheim. Schauta, see Fig. 207) . 

The oi>eration is done in the following manner: A sagittal 
incision in the median line on the anterior surface of the vagina, 
going as far as the posterior part of the urethral meatus. Si^para- 
Uon of the flaps from each side of this incision. Posteriorly, 
in contact with the bladder, make a transverse incision which 
leads into the retro-vesieal space, which is separated. Open tlie 
vesico-uterine cul-de-sac and tilt the uterus anteriorly. If the 
woman is in the [H-rifKl of sexual activity, in order to avoid con- 
ception ligature and cut through the tubes (Kig- 908). Then 
draw the ulcni-s into the antcllcxcd ])ositiori and close the perit- 
oneal caWly above it by suturing the retro-vesical peritoneum 
lo that of the pasterior wall of the cervix (Fig. 200). The uterus 
is then lodged in the niche created by the incision and separation 
of the vagina, its posterior wall being in contact with the bladder 
and its sides with the diliedral angles resulting from the separa- 
tion of the incision. 

The vaginal fiajw are sutured above the uterus of which 
a small portion remains exposed in the vagina (Figs. 3ifl and 911). 
This is of no imiM>rtan<'e. as the uterine surface iH-conies covered 
with epidermis during the weeks following the operation.' 

This o[}cration is not always possible. 

If the uterus is loo big to lodge in the space created by tlie 
separation of the vaginal Haps, we do a hysterectomy. This 
is done by Landau. Once the uterus is " inverted *' in the vagina, 
he closes the [writoneuni with silkworm-gut sutures, which 
unite the peritoneum of the pouch of Douglas with the superior 
angle of the vaginal incision and iJie vesical peritoneum and 
which takes up some uterine tissue en paMiujc, so tliat the pos- 
terior wall of the cervix is fixed in an elevated position. Liga- 

■ Watkiu, Jim*. Gyn. unrf OA«ffi. J., Nov., im^-.Svrg., Ova. and Ofaafet-, June, 18D6, 
p. O.W. 

' Hiuitinic* Twi^y coniliiiipx an analnKoiM opentioD by wlure of the two Itroad lig*- 
lumU in itual of ttie Uthniiut, whirhtiarry thp cervix up and back. Koribftt. aftw m- 
reitiitK Uui ntcnu intu the vs^nn. he uiiitp* thn biuMi o( thn hmiul lip.nmonl* ricar their 
pdvie eximmilv with ilrona lilk ami tip* thetn UiR^lhcr. (F.. lIiwiiNK" 'f wi-e.l.v. Cura- 
tive Opcrolion for Procidviitlii l.'t«ri. Jvuni. o/ ObnKI. and (lyntc. of ihr BrilUh Emmrt, 
LMdon, tWU, T. J. p. 340.) 




22fl 



I 



jVntcrior colpo-odiolomy. as done by Doyen, conslsfs in )in.t!>iiig a loop of 
sutUKit 3 mm. iltH-it nixl 1.^ nun. hroiul into tho siib.stnnoo at the uterus and 
then the needle in |)n§sed tlirouftli the sii]»(Tficia! hiyer* of the siiin-jniif-iriiil 
poriion of Ihc wrvix. Tlie exlrcmitit^.i irf the .lutiire are now lied and thus 
fihorten ihe untcrior wall of the uterus (Fi^. HA). 

\ tfiiifiifxriiig siiluiv. inM-rled aliove Iho first, assures the success of the 
operation. 

K)iM-h«r rcserts fn>m the uterus which has heen drawn into the vaginal 
wound, a U-shajR-d flap. lie denudes (Ik* anterior surface of the (-crvix and 
tlH:n briugt Uie llajt and dcnudeil surfaee into apposition and fixes ihem. 

7. Siwrtening of the Vtrrinr Ligammls. — After anterior Milpotoniy us 
donr : 

a. ShortentNg of Oie round liyamatls temporarily drawn into the vaginal 



I 
I 




Via. 211V. — Ineiiiion at the anterior turuix and anlorior wall of the utcruii (Oui). 

wound (Bodf, (lodinhn), eotnliining Moiiielimes lliis shortening; with vaj^ina) 
fixation of Ihe ligaments (Wertlieini. Vinelier^'. Hall). 

6, ShvTiening of titr largr Hijamriils .sutured one to the other in front of 
tlur uterus (Kochs). 

8. ticdutiiim (if I'trrinr InrrTKuin. — Sjiirielli. after urilerlnr eid|Hilomv, 
mnkesananalogousojieraliontothat which I'iceoliadvocaled hy the posterior 
route. On IIh* index inlnuluced into the funnel formi*<l by tJie inverted 
Dteru-i. he incises the cerxix vertically and the )interir>r wall of the uterus up 
to Ihe fundu.s wf thai ur^iin. After redudinn. he sutures Ihe uti-riiie inmiun 
and concludes with a vagino-fixation neeordinf; to IXihrssen's method. 

In Franetr. Oui opi-raU-d in the following manner: After drawing Ihc 
Dli*ru.s out of Ihe vulva, he makes just alinve the external os. which i^ easilv 
rreognized by ■"iuhl (change in eolontlioii) and l.y pal[mti»)n (ilitfiTriiee in 
Ihiekw-n*) a semicircular incision wliich opens the anterior fornix freely. 




230 



O0LP0TOM1E8 



This iiidsion should be vcrj- fxtensivi- so as to cnnblr Hw operator to «a.<ily 
return the uti^rus back Ihmiigli it into llie altdorainal cavity. 

Anterior (.■olpo-c*'liotoiny liavinp been done, the infundibuliiin of lla- 
inversion is examined by dijfilal exjiloration in order to be quite sure it 
eonluin.s no other organ (bladder, intestine) which might be injured by the 
incision. 

With Meis.wrs or a blunt bistoury, guided by the fln(jer. tlic anterior wall of 
the uterus is incised in the median line in all iU thickness from external os to 
fundust (Fi^;. Hit). 

Now tlic reduction .sta^r arrives. The thumbs are applied to the poste- 
rior wall of the uterus: the index-fingers seize the lips of the uterine incision 
and draw them out and in .«j doing unfold the ufi^rus C^ig- 210. In con- 
tiiiuiti^ this movement we gradually eoroplele the reinvrr!*ion of the urgaii. 
The fundus of the uteru.« is then directed down and forward, the cervix 
assuming a position pointing up and back. 




Fio. 216.— Rein version or the ut«ru« CChif]. 

The utertLt having been reduced, the wound is united from fundu-s to 
isthmus bv an internipl»-d caljiul suture. The iiutiin-x an- uhout 1 em. apart 
and tjike up the entire thickness of the uterine wall with the exception of it.s 
mucous membrane. Between these .suture.'* other catguts are placed, taking 
up the serous coat and the superficial layers of the muscular in such a man- 
ner Hx to get accurate iippiMilion of the peritoneum. 

Thefundusof the uterus is then pushed up and back and returned through 
the vaginal incision into the alxlomen. 

The cervix is nutured with catgut as also the vaginal fornix. 

Results. — Immaiiule results of anterior t-olpotcunv arc fiiirly 
good. Dulirs-sen in j03 ca.ses liiul fifteen deaths; Martin had 
only t'ovir in -171 cases. 'I'lic hiaddcr l.s Ics.-f often injnn-d llnin 
one would think a priori. Martin lias had this occur, however. 
in five of his interventions. 





FlO. 218, — The utcnwtma beer replaced hy the vugiiiiU iiicixioD, Tlinmryiinaino now 
only th» ftuturc o( iKr iilcrint" ecrviit iiinl of thi- anterior fornix. 




Fni. 219— Opomtion («rmmiit4M! (Oui). 



280 



Tins iiii i 
n-hirr] 1 1 
All). 

('Diitiiii 
iiii'i^i'i' 

t)l(' ril' 
fllll.hi 
N 

riiir V 

iin.l 

tiliiii' 



. ■■'Xii !irc licalMiy or 

"'ists ill tilt* fixation 

--■ --.I. \Yliat »ro tlif 

The [>n>|i(irti(iii of 

■ ■ roceiluiv ciniiliiycii. 

■villi till' jiniccduifs 

■ .- is fixed. 

■ remote results iin- uf 

■ ■■■..-, tidii. 'I'lu'se coiiipli- 

■:: iri or piviiiiitiiri' ialmr; 

-.■i^inaiin. Also (ivslocia 

-..!;_v duriiij,' labor, 'i'lit- 

-\.liisivc'lv at the expense 

.iuses the os to look ii|> 




i'li;. JJI. 
- --.iicln:!] lixatiiiii I KIciiitvucliiiT I. 

^ \-i-' . Wlien the head enters the 

V ilistendiiij,' tliat |>arl of the 

--, riie eervix anil llie fixed point 

-. OTii.iified hut <'overed over hy the 

:;-.o ivrvix is vi-ry liif;h. sometimes 

:• ;i\is of Hie <'hild may he in these 

*-;;dieillar to the axis ai the pelvis. 

:\>ii!t of the pressure <)f tlie anterior 

: \:tf»- iif its liilliii'inv riM I'rcKiiiiiicy. .I'.n. 



ANTERIOR COLPOTOMV 



233 






slHlominnl wall of the uterus, deviates an<I a transverse presen- 
tation i!i [>n)<luce<]. Accurdiiij; (o Kiciinvuchtcr this occur!! in 
IS.ai per 100 cases. 

The complications in difrcrcnt labors have also another 

cause. The union of the anterior wall of the uterus and of 

Uie correspond in}j wall of the vafjina produces at the point of 

union a fibrous cicatriciul area, upon which the development of 

pregnancy has no influence. Also it is common to observe that 

cluring a [wiin there is a ri},'idity of the anterior hidf of the cervix. 

^ If this is borne in mind and also the j>iirt that the postero-superior 

]*v"all of the uterus plays ilnrinj; IjiImh, in .sh()rt, practically the 

Mltire role becoming very thinned, one can easily understand 

ru|>liircs occurrinji at this level. 

^ Since then defenders of vagi no- fixation have endeavored to 
void dystocir coniplii-alions. 
From this Duhrssen's procedure takes its origin. We have 
ulrcady deserilx'd it and his method endeavors to replace the 
fil>rous cicatrix by simple [jeritoneal adhesions, susceptible under 
the influence of prejjnancy to undergo the important anatomical 
modifications which lead to increased size of the uterus. 
H Indications. — In short, with the exception of the abstraction 

of pre-uterine suppurative eollections where anterior colpotomy 
may be employed as the operation of necessity, what other cases 
present them-selvrs f(»r Its use? In a general sense when it is a 
Question of the extirpation of uterine tumors, such as fibroma 
*^f the anterior wall, or para-uterine tumors, such as ovarian 
'^ysits. it appears to us as an oi>eration which is inferior to that 
'*f the abdominal route. It is even iirmlv contraintlicatci] in 
*<iherent tumors and malignant tumors or solid tumors larger 
*l»aii the eIo?ied fist. 

In retrodeviations complicated by extensive adhesions with 

i^ighboring organs, anterior colpotomy. whieli gives a limited 

Operative field, should be rejected and we would, without hesi- 

'fttion. choose the abdominal route. IJul, in simple cases of 

"dhert'ul or slightly adherent retroflexion, with healthy or slightly 

'lisea-sed adnexa. anterior colpotomy may give good results. It 

Qts l))c advantage, if it is combined simultaneously with a 

Curettage or colporrha])hy. of fulfilling the diiTerent indications 

purely vaginal intervention. In such a way one avoi<ls the 




234 COLPOTOMIES 

loss of time which must occur as a result of the changes of 
position of the patient. 

Personally, we prefer in these cases the abdominal operation. 
If, at the same time, it is decided to try a vagino-fixation, wliat 
proceeding should one employ ? All depends on the age of the 
patient. If she has reached the menopause, if she has under- 
gone a bilateral extirpation of the adnexa, we may have recourse 
to a direct and extensive vagino-fixation. If it is a young 
woman, capable of pregnancy, we advise Duhrssen*s operation. 
This operation does not put all recurrence out of the question, 
especially if pregnancy occurs. But the possibility of a recur- 
rence, otherwise problematic, is nothing compared to the cer- 
tainty one has of avoiding the redoubtable dystocial complica- 
tions imparted to the primitive procedure. 

In i>roIapse, the operation of Wertheim-Schauta which con- 
sists in fixation of the inverted uterus in anteflexion and the 
forcing of it into the substance of the vesieo-vaginal septum, ik 
counts a certain number of partisans in Germany. The same 
operation lias given us, as also Hofmeier, good results in 
l>ellious cases of incontinence of urine. 



CHAPTER VIU. 

VAGINAL HYSTERECTOMY. 

Summary. — Tcvhnic (prc-opcrativr precautions, operation, posto[Krn- 
tm precautionti). — Operative difficiiltic-t. — C'oiuplivations. — Various pro- 
chares (Dojxn, P^nn, Second. MilUpr. Qu<5nu, J, L. Faurc). — Operative 
modification)! according to the IcHinii (caiicfr, tihronialu, inflaaied adnexa, 
ptierpcrul infection, prolapse, uterine inversion, juxta-ulerine tumoni). 

TliL- first surjfcon to excise the uterus with siicwss by Uie 

vajjina! melhodwas Sauter uf Constance (1822). He operated 

wjidout forcc|»s (>r ligatures and yet his patient was cured. In 

iS-ig Uecatnier did the same operation, but ligatured tlie uterine 

frtcries. Unfortunately the high mortality luade the o])eration 

<h11 into oblivion, from wliicli it was restored to the light by 

^'zemy, who on the twelfth of .\ugust. 187S, did a vaginal 

"Vsterectomy for caneer of the cervix. At first, vaginal liyslcr- 

<sctomy was reserved for this affection. Its indication, however, 

*oon became more extended. 

Tlianks to Pcan firstly, to Segond. Richelot and latterly to 
-t>oyen. vaginal hysterectomy was applied in a systematic fashion 
*^o treatment of the adnexa. and then to fibromata. 

lU operative technic has lioeii considerably sini])Iified owing 

»^*^ the introduction of forcipressure and to morcellement. 
Among numerous ojwrative procedures wliicli were succes- 
■'^ively utilized, we should give a place apart to that of Poycn to 
^'^"lioni is duo the merit of introducing a technic so simple anti .so 
^t*~**^pid as to vulgarize vaginal hyslcivctomy. 

^B In spile of the operative perfection and the excellence of the 

^^'^sults. vaginal hysterectomy, having had a wry cimsiderable 

"^Ogtie in the treatment of inflammation of the adnexa, fibro- 

***atn and caiici'r, has lost imich ground and tend.s more and 

^*>ore to lie replaced by abdominal hysterectomy. 

235 





,336 



VAGINAL HYSTIJRECTOMY 



1. Operative Technic. 

Preparatory Precautions. ^Vaginal (lyslercctomy renders c 
tain pre-operalivf prwautions necessary which it w iin|H>rU 
not to neglect. Several days iHrfore the o|>eralion the pati* 



J 



Kio. 332. — Sliort viigiiisl 
qieoulum. 



Ki». 333. — I.oru; iiii<l lutnaw ipMulum, 



will lakp larfje vaginal injections twice daily. Give a pu: 
tlie night iK-fore the iiitervciitiim. 

Before operating look to the toilet of the vagina and vul 
This is a lengthy and minute operation. The vulva should 



I 



Fh). 234. — Huwui's liMvy (onMtp>. 

completely shaved; wa.'ih with soap ti«il only liie external 

but also the vagina itself. 

The following is a lis! of irislrurnenls rer|uircd: 
Several vaginal s|>ecula. one about 5 or 6 cm. loi 



I 




OPERATIVB TKCHNIC 



237 



press down the fourchette, two ordinary vaginal s|>eciila, two 
lon|^ and narrow .spcciilii uliotil 35 mm. long iti onli-r tu protect 
the bladder, some tjinipon holders, si\ [Miirs of Museux's strong 
forceps to draw the uterus down, one hysten>meter, one hi'stoury, 
some slrniglil and cun'ed scissors, pressure forceps, one i>air 
of tenaculum forceps, some Korher's forceps, two ring forceps 
to draw ou the ndnexa and eight pairs uf short and powerful 
pft'ssure forceps. 

The relative position of the operator and his assistants is 
Uie same as for all vaginal operations. 

Two asi^istants are iudUpciisahIr; one is placed to the right 
an<| the other to tJie left. 

Tlie instruments are to the right of the operator. 

In order to avoid any sepsis tlie o[M.'nitivi' fielil should be 
^ extensive. It is important to fix the posterior compress so as 
H to conceal the anus. Three little tenaculum forceps arc dis- 

"l*<ised so that one is qn a line with the fourchette. and two 
"^tilers over the buttock; fix this compress and in onler to be 
^Mite sure of the fixation allow them to take up at the same 
*'*ri3e a little fold of the subjacent tissues. 

The bladder is emptied xvith a catheter. 

Operation.- — The ojH'ration should then commence. 

'liie fourclieWe- Iteing ]ircsse<l down by the short s|>ccuKim, 

^■i« cervix is seized with t%vo pairs of traction forceps inserted 

**>to the anterior Up near the commissures. The liohl should 

■»^ firm: the uterus, by slow and progressive traction, is drawn 

*^own to the vulva (Fig. •iiO). Holding the two forifps in the 

^^Ft hand tlie operator, with scissors or a knife, held in iJie right 

■^tuul. makes a circular incision of the cer\'ix. The majority of 

*Urpeonc make a circular incision. We I>elieve with Scgond. 




Fio. Zti. — Bbort fttid Mniug artery forocpn. 



I 





J 




prcssuig down with hi-x tvlrwctor the <orres[>onding vaginal wa 
wliilt: the Kur^eon with his left hand draws the cervix sitrtingi 
towiinl tlif left. The f«»riiix'is thus well exposed and stretchw 
Taking the bistoury, the o]>erator coniiiK-nrcs tlic incisioD > 




OPKIUTIVK TliCHXIC 



239 



5 fornix alioiit 4 vm. fmin tlu' right f*»mnii.ssuiv. This incision 
lircctecl at first transversely toward this commissure but %vhcn 
1 bistour\' is ahout I 1/2 cm. from it the instrument is directed 
word and cuts through the anterior fornix on the e<Tvix. Duf^ 
; this procedure the cervix is cirawti toward the right. TJie 
Struelor now piays its role in tliot it permits of the knife 




^H FiO. 'iiJ. — Circular iiidwon of tbe ccrrix with Inloml incivioof. 

tnaking a short lateral inei^iun in the left fornix symmetrical 
:h that on the opposite side. 

In inserting a [Misterior s{>eeninm and in drawing the cervix 
■ward, one is enabled to circumscriiH; tlie ctT\-ix by tracing 





240 



VACJl.NAL HYSTERECTOMY 



a furvcd incision posteriorly, and flien proceeding toward Ihi 
front about 1 l/i cm. from llie external os' (Fig. 1^48). 




i 1(1, 238. — Posterior part of the drotilAr incirion vt the oarvlx. 

The danger is the Madder; h_v keeping ahout 15 lo 18 nil 
from tlic cervix tlicre is nothing to fcur. In case of doubt n^ird- 

I Hmim opvrfetora pnfor to alUck the v»Kuia witli atronK curved friuon. Tbt 

KIs ■liriiilil lie (uunilnl on ibt poMcrior ri^it faea. T)ii: lirft bnnd dravring on tbt 
■|H piilln a liKnard und the leiMon rtit inlu the ri)i:lit of tlie wtvix (to l«dt of the 
Opanl'if I ul'iiiil 2 am. from Ihi' pxtcranl im miiI with ntmo few cutn acivr tlic poiit«tiw 
vmltuU imnliiTii ofirn tW (louih ol DoukIu Ja opcnod tt> this maniimlnltoii. l>ul (1 
ittl aa tiniiorUuiM^ Wheii th« MiMon is on tliv Iprt ddc uf ihi- L-vrni, tlie loft huid 
MBlpulklwltiMahk waywtaexpateolcArly t)i«lateTftt mirfftcc, ttiim tli«MiiefiormrfM« 
MtM oer*ls kti'l (he Huoon circumaerilNi tbt- oervix by cuttinK throiuh th« tnwrtkm 
ill IIm iBipiin. tlinir cxtrrmity. kppBed to tho litems Mvcr* lEraduKltjr tho ftnt«rior 

InMttliin of tile va|t>ria anil llicn fOM to the Irlt of tho opcnttoT to unilo with tlw linl 
nitUt»ii Ml tiN ■lorlins point- The duinitrrluia of the roipiLK U iiDiabed (i. L. Paun^ 




opERATtvr: Ticcnsic 



241 



;its limiti there is nothing simpler tlmn to introduce a sound so 
to accii nit<*!y determine iU liniiLs. 

The cervix thus circuiiiscriljcd should be freed. Commence 

opening the posterior fornix. To do this, the cer\'ix being 

■riwJ forwurd, the index-finjjer is forced between the Ups of the 

sterior part of the vaf;iniil incision and endeavors to bnrat 

xjugb the [H-ritoiical cul-dc-sue. If tJiis is free, the action is easy 




R 



Fid. 226.— t36p«ralion of tl>« bladder. 



e finger sn<»i feels as if it were in a cavity. %vhere it feels 
testinul K>ops or even prolapst-d adnexa. 
If the cul-th'-sac is fidl of adhesions the |)eritone«( cavity is 
fGcult to find. It is in these eases that we nuist proceed nie- 






'I'lic uterus is freed Fiehind nnd now it must lie frefnl antiv 
riorly. 'I"u do my. carry the n-rvix tUtwn iiiid back loward Uie 
fourcltettc, separate the Ittaddor with tlie right index- finger (Fig. 
K2U) nr with lihint curved scissors which timy l>e used to press 




I 

I 



hack Ihe lissues and also to cut throtigh tlu* pjirts which resist 
the se[»a ration. 

Above ali, at the level of the median line adhesions are most 
marked, as we have alrciulv had oircasion to observe when describ- 
ing anterior colpotomy, 

'I'lie separation of tlie bhiddrr should In- very eomph'te. It 
is curried out as extensively as |)ossil)!e laterally in order to 
sefMirale the iin'ters from the operative field. 

In the course of these manipulations the vesico-uterine cul- 
de-sac is often o]>ene<l. If it is not. it may l>e recognized by its 
white color, which dilTcrentialcs from IIm- neighboring celluhir 
tissue and may \ie opened by a siiijrle cut of the scissors. 

When tlie utcrns d<ics not descend well and the [K-ritoneal 
cul-de-sac is not lo lie seen, we should [jrocced without waitinj* to 
the next stajji-: Anterior }iemtnrrf'um of fin' ulcrit''' or median section 
of the anterior wall as recommended by Doyen (Fig. ^30). 

'I'his heniiscction is done in the following manner. Two 
traction forceps are placed at tlie level of each of the commissures 
of the cer\-ix. The posterior liml> of a pair of straight binnt 
scissors is inlrtKluccHl into the cervical cavity and Ihe anterior 
wall is cut through as far as the isthmus, or even a little higher. 
remcnilHTring always io follow exactly the anterior median line. 
This cut does not bleed. On each lip of the incision, as high as 
jMJssible, plac*' a pair of tra<-lion forceps. 

By <lrawiiig on these forcep-s. wliidi hold llic uterus verj' 
firmly, its anterior face is sensibly depressed and at the same time 
a slight anterior flexion Is imparted to the organ. 

A new part of the uterus, not incised, now appears. Taking 
the scissors again, the surgeon cuts through all the visilile [lorUon 
of the accessible anterior face. A third pair of traction forceps is 
placed on one of the lips of the incision above the first pair (Kig. 
iSl). This pair may then be taken otl" and reattached on the 
niasi elevated p<»rtion of the opposite lip of the same incision. 

One ascends tims toward the fundus of the uterus, in a sense 
making the traction forceps climb the anterior median incision 
which the operator continues to prolong. This |»rogressive a.sc<-n- 
sion of traction forceps bring.'s alxjut a more and more marked 
tilting of the ImmIv of the uterus. In the meantime the vesiet)- 
uterine cul-*ie-,sac lias been opened ; it long and narrow speculum 




244 



VAUIKAL HVSTKKECTOMV 



is introiliiecci into its cavity, protrctiiifj; the Marlrlcr and pressing 
back the loops of int^-stino which tend to descend. When the 
inc<llan anterior incision approaches llic funchis of llic organ and 
the' traction forc'e|»! arc inserted very close to this point, tilt-fl 
ing of the uterus occurs and llie hody is turned completely iiisiiJe 
out into Uie vagina (Fi^- iSi), 




Fro, 23 1-— Pros 1 1 



I iitioii [>f the foret^i lu the bcntiBuction promHiiJH. 



We must now free the adnexa. Commence with tliosc on tli 
left side. The index-finjjcr and inediiis (»f the left hand are iiilrt 
duced above the fundus of tlie uterus and are directed toward tli 
posterior aspect of the broa<l lifj;am('nt and Uieii they conunence 





332-— Tbu incuiui) bus rcnolMHl ihc fiiii(tuH «( the Dinnn. The \tody «f iKo uterus 

is lilf<il (orwunt, 

I 

1 this sepHraition. Having freed llie Hcliiexa, these are directed 
■U'linl till-* uterus and liemostosis of the hroiul lipiiiu'til is carried 
IL In order to do tins, cliarge the assistant to the rij^ht with the 
n of the uterus, and rfrjuest him to gtuith* draw it to his side. 
\Ka place the clumps in position under the double control of 





246 



VAOINAI, HYSTERECTOMY 



eye and fiiiger. In no case place forceps on a broad ligament un- 
less under <Tontro! of the eye. A shorj and strong pair of arterj' 
forceps, the model of which we have indicated, is attached from 
below up, external to the cervix; it is made to seize the interior fl 
lialf of the broad ligament where the uterine pedicle is situated. " 




flo. 2S3. — Frwiog of left ndncxn. 

At the same time tlie tw(> fingers of tlic left hand, introduced into 
the recto- uterine cul-de-sac. keep away the intestinal loops. A 
similar pair of fortTjJs is attached in the inverse sense, that is, 
from above downward, to the u[j|ier part of the broad ligament, 
external to the adnexa and .securing the sujjerior pedicle. The 





OI'EHATlVli TKCHNIC 



249 



If the operation liiis fjonp along siinKtlhly and typically, Ihese 
four forceps are quite sufficient to secure hemostasLs. 

It is. however, not always thus. ) n any case, l»efore regarding 
the niieration as terminated and doing the dressing, it is necessary 
to make a serious examination of the parts. To do .so, separate 
one fn>ni tlie otJier two groups of forceps, whidi an* <loiiig duty 
as lateral retractors. Place anteriorly and posteriorly two long 
and narrow fijieculii and witli a tuin|)oii of gauze hehi in a pair 
of forceps, proceed to the toilet of the parts. One is thus able 
to see if any oozing is going on. If oozing exists, wc must find 
the bleeding point and arrest it. If we are quite sure that tlie 
hold of the four chief forceps is perfect, the bleeding may have 
many origins. It may come from tears produced during separa- 
tion of the adnexa ; these tears are usually on the posterior aspect 
of the broad ligamenLs. It may come from Uie summit of the 
diliedral angle formed by the folding of the broad ligament: in 
these cases the hlo<M) c-omes from tlic arteriole of the round liga- 
ment which has escaped tlie forri pressure of the upper clamp, 
Finally, the vaginal ineisiou may be the soui-ec of the hemorrhage. 
In any case, if the source of the hemorrhage has been discovered, 
it is easy to apply foreipressurc to the bU-eding vessel. Then 
we again turn our attention to the bleeding, and if hemostasia is 
absolute, we go on to the dressing. 

This is done with several precautions with the aid of a long pair 
of vaginal dressing forceps. Two long strips of iodoform gauze 
are introduced. These gauze wicks should not go beyond the end 
of the clamjxs in such a manncras to prevent the contact of tliese 
latter with the intestines and linally to .separate as widely as |>ossi- 
ble tlie intestine from the ligamentous stumps. The exterior 
extremity of the gjiuze is folded u]i in Uie vagina. A new gauze 
is interposed between the forceps and the fourchette in order to 
prevent the dii-ccf pressure of fonvps on tJie nuicous membrane 
and to iJius avoid tlie production of little excoriations at tliis point. 
These are always painful and present a .source of infection. The 
[Mttieiit's bladder is calheterized. the vulva very carefully cleaned, 
and then coveretl over with a large layer of hydrophile wool, in the 
center of which is an o|>ening to allow passage for the vaginal 
forceps. A T-sha|)ed bandage completes it all ; finally, be careful 
to unite the hantllcxof tJicforeejWi with a pietre of gauze lfH>sely lietl. 




{ 



2fi0 



VAGINAL HVSTERECrtlMV 



I 

1 



Postoperative Details. — l''he putient is kept r|uietly in l>ed i 
in order lo uvuid any movement which may affect the forceps. 
Raise the patient slightty so that the force[>s do not repose on the 
bc<J. The two thighsof the patient, united wilh a hroad servietle. 
are maintained in Hexion hy a pillow placed under the popliteal 
spaces. 

The immediate postoperntive treatment is nothing sj>ecial. 
It is Uial of any ofwratinn in which the peritoneal cavity i.s openi>«l. 
Abstinence from foo<l until evening: then alcoholic fluid (clmm- 
pagnr or grog), taken in snudl r)uantities at regular inter\'al5. 
\s early as the day following, give liquid alimentation if no 
inflaminaton,' complication occurs. 

TJie patient's bladder shouhl lie calheterizccl. This should 
be done at intervals and is of much greater benetit than to leave 
it in continually, a course ne must deprecate. A tmrse should 
remain by the bed, watch the patient's movements and keep her 
on her back. 

Certain surgeons apply an ice-bag continually to Ihe abdomen 
in order to lessen the pain. 

The forceps are taken off forty-eight hours after the o|>eration. 
This is done very simply. Each clamp is carefully undamped: 
then a slight movement of rotation is given to it in order to detach 
the blades from the tissues with which they were in contact. 
This Wing done, the clamp is gently drawn out, without jerLs 
and al>ove all without force. If in spite of these precautions, 
one finds tlifficulty in removing Ihe forcejwi, do not insist. IJn-f 
clamp and take away tlie neighboring ones; that suffices often to-" 
render easily removed the recalcitrant pair, .\fterward, after 
removal of the forceps, proceed to a rapid cleaning of Ihe vulvs' 
and once more re-apply a layer of sterilized wool. 

The gauze wicks are removed on the fourth or fifth day. To 
remove lliem, the [>atient is taken to the o|x-ratiiig theater. This 
permits of washing the vulva with more care and enables the 
vaf^na to la* thoroughly cleansed licfore the insertion of new 
gauze dressing, which will Ik.' purely vaginal now. 

Comments vaginal injections on the eighth or tenth day. The 
cannula should he hardly made to enter the vagina, the vulva is 
maintained o|>en and the jiressure reduced to a minimum. The 
patient may get up on the fifteenth day. 



I 




OPERATIVE TECHXIC 



3fil 



I 



» 



Operative Difficulties.^ — The vaginal Iiy.stererlomy may lie 
very «iifiicuU h\ rfii.suii o!' the tighliifss of vulva and vagina, 
by fixation of the uterus, by its friability and ndhr-siuns round 
about 

Wlien the narrowness of vulva and vagina is not too consider- 
able, .simple flijatation with .spceulu at Ihc eommeiiecnuMit of the 
o{)cration suffices to give them sufficient dimensions. But if the 
stricture of the parts, congenital or ae(|uired, presents a very 
marked degree, it is necessan.' lo change the constricted nature 
of these tissues Ijcfort* thinking of a vaginal hysten-ctomy. The 
clifTerent varieties of vaginal incision and se|>arntion, which we 
iiave had occasion lo descn'lie, appear to us to be indicated 
only exceptionally. It nmy be sufficient to use repeated tam- 
giHining of the vagina or to dilate it with Gariel's pessary. We 
should not hesitate to employ these means; it is belter, however, 
mn these eases to use the abdominal route. 

The uterus is usually fixed by peri-uterine inflammatory 
lesions. It constitutes an operative complication of the most 
sinnoying deseriptinn and n-nders the <lrawing down of the 
uterus so difficult tltat one has to have recourse to morcellement 
<iF the organ. 

The difficulties are maximum when to this ftxatton of the 
uterus is added friability uf tissues. It is then quite impossible to 
attach a pair of traction forceps without tearing out a piece of the 
tissue. This friability occurs in hysterectomies soon after a 
pregnancy or abortion; it may also be si'cn, apart from |m'g- 
naneies, in cancer of the uterus and in some special forms of 
parenchymatous nielritis. We must then, according to .1. L. 
Faure, replace traction forceps by forceps with a broad blade, 
such as arc used in ovarian cysts. The large hold prevents the 
ccr\'is from being torn. 

We will not insist on the difficulties due to adhesions of the 
adncxa, as we will return to this point when we study vaginal 
hysterectomy in ca.se of salpingo-ovaritis. 

In a general way, with patience and method, we can triumph 
over these difficulties. If. however, they are loo considerable, do 
not continue too long on an o[H-ration which lis so difficult, but 
abaudon it for the abdominal route. 




252 



VAGIXAL HVSTKIiKCTOMY 



1 



Complications. — Wc nmy-come across, during or after a liys- 
tcrectomy, a ocrtnin iiunilier of complications wliicli it would be 
well to go into. 

Hemorrhages. — The most iinporiaiit complication is hcmor- 
rliage. It may cnirie on <liiring the performance of vajijinal 
liy.stcn.'ctomy and results genorally from some ojH'raUvc error. If 
one takes care to proceed in a methodical manner, clamping tlic 
tigamenU before cutting them, and to proceed always under direct 
control of the eye. there is every chance of avoiding Iicmorrhagc 
during the operation. 

If the hemorrhage comes on some little time after tJie oi)em- 
tion, it is due generally to breaking or slackening of the hold of 1 
one of the clamps which assures the hemostasis of the linmd liga- 
ments. It comes on usually when one uses long-bladed forccjw. 
nml when one has applied only a single forceps on each broad 
ligament. In the procedure we have advised, by using two 
.shorter^bladcd force|»s, all such accidents may be in that manner 
avoided. 

In jiresencc of a hemorrhage due lo Uiis cause, -seize the point 
tliat bleeds through the vagina. But most imftortant to remember, 
do not tcork in the dark: The [latient should be anesthetized, 
if necessary, and conveyed to the theater. The sfjocula cxpoise 
the oi>eralive field. Do not forget that these attempts to secure 
secondary hemostasis have often woumled the ureter; for tliis 
reason d.o nol pinch up a part with the forceps until one is quite 
sure of all freedom from dangiT. Prepare as for an abdominal 
celiotomy. If the attempts to arrest hemorrhage by the 
vaginal route n-main fruitless, do not hesitate but search for the 
bleeding point by operating through the abdomen. 

The hemorrhages which surce<'<| the removal of the forceps 
are justiliable of a similar line of action. It has Ijcen n.'coni- 
mended that, in order lo Hvoi<l this cumplleation. one sliouM un- 
clamp the forceps, and leave them In [K>silion for about nn hour 
afterward. If hemorrhage recurs, nothing is easier than to 
rcelump. 

This procedure is little practised and it is dangerous also. A 
loop of intestine nuiy come IjcIwccu the separated blades and lie 
imprisoned at tlie moment of reclamping. Like all these blind 
manipulations, they sliould be avoided. 



I 



OPERATIVE TECHNIC 



233 



The Iicmorrlio^s which come an alxitit the thirteenth or 
fourteenth day come from infection as in nil secondary heinor- 
rhitges. They sliould be treateil with tampons of iodoform gauze. 

Lesion of Neitfkboring Organs. — A certain number of organs 
may I>e injure*] during the operation. 

Wound of the ureter is rare in the hands of an experienced 
sui^on. In 4.50 vaginal hysterectomies, Segond only had two 
cases. In (he great majority of cases it is tlie right ureter whicli 
I is injured and the reason will be seen later, 

The ureter may be W(>und<-d iti the incision of the cervix. 
This particular section of the ureter is exceptional and it is easy 
to avoid by incising the vagina on the cervix itself, and at a little 
distance from tlie external o8. 

Much more fnMiucntly the ureter is wounded during forci- 
pressure on the interior portion of the brna<l ligaments. This 
inelusiun of the ureter has two reasons: (irst. an insufficient 
liberation of llie anterior face of the utenis and broad ligament; 
second, to a too obli<|ue attachment of the clamp. 

It is shown thai when the uterus is drawn down toward the 
\njlva, it tends to become enclosed between the two ureters, and 
that these, normally se|)aratC4l from the rervix for a distance of 
12 to 15 mm. come to lie in contact with tlie uterus at tlie level 
of the isthmus. 'I'he freeing of the anterior surface of the uterus 
and of the broad ligaments corrects somewhat Uiis displacement 
and thniws the ureter outwanl. The lateral incisions, added 
by Segond to tlie circular incision which circumscril»c's the cervix, 
facilitate greatly this pressing back of the ureter, in permitting 
the sc|«tralioii of tJie un'tert>-vesical and utero-vaginol planes 
latenilly. 

If one thinks of the inconvenience of placing elam|>s in the 
oblique position, it is enough to make one avoid this operative 
mistake. If one represents tlie jiosition of the hands of the o[kt- 
ator at the moment of clamping the right broad ligament, it is 
easy to gras]> why one is more expose<l to commit the mistake on 
the right side. This explanation also suffices to explain the 
great fre<picncy of lesions of the ureter on this side. 

Still we do not think it right to blame such and such an 
0[ierative procedure, and the reproaches directed to the opera- 
tion by "Iwiseule," or inversion of the uterus without preliminary 




354 



VAGINAL MVSTEItECTOMY 



ampuUition of the rervix, such as Doyen does, lio not appear 
Ik* fouiideij. 

Finally, the urethra is above all exposed to be ]jinched up in 
the course of nlypic-al inaiiipulattons. re<iulting from an abnoruml 
anatomic-al dis{>osition of parts or an unforeseen operative 
eoni plica lion. In one case il niiiy Iw due to the coninientToient 
of an invasion of the broad li^antent by a neoplasm which obliges 
one to place the clam[>s laterully: in another case, il is a hem- 
nrrha(ie due to impi-o[)er application of a |Miir of forceps or to the 
slipping off of foree])s, which h-ads us to add a supplementan,- 
jwiir. For these abnormal circumstances, it is impossible to 
give precise rules of action. It is well lo recall thai in these 
atypical cases it is particularly the case to avoi<l proccetling in a 
blind manner, and not under control of the eye. 

If the ureter is cut across, the urim- commences to run into 
the vagina some hours after the operation. But, as most often 
the ureter is injui-ed by l«-ing pinched up, the discharge is only 
proclu(T<l when the scar lissue comes away, from the fifth to the 
eighth <hiy. If it is a question i)f an inclusion lalerHlly, rt'nal 
pains more or less severe may cause a sus])icion; if from the 
liegiiining of this operative complication, it is, however, not 
constant. 

We will have occasion to return to the treatment of these 
nretero-vaginal lislulas, following on liystcrectomy. 

iVounih to the Bladder.— Vi'ound of the bladder is more fre- 
ipit-nl. Segond observe*! this five limes in 400 cases, 'llw 
bliidder is wi>unded sometimes at the moment of incision of the 
Hriterior fornix or mayl^ at the moment of liberation of the sul>- 
periloncal portion of llie anterior face of llie uterus. 

In contradistinction to ntero-vaginal fistulas, Uie vesico- 
vaginal one may somi-times heal spontaneously. 

IVouiiih ((/ flir tteelum. -The wounds of the rectum are far 
from rare (nine <'ases in 20r» (ijK-mtions. after Segond). Often 
prepared by lesions of the rectal wall, they are often produced at 
the moment wlien one frees the posterior surface of the uterus. 
They may heal spnntaneously; we have already considered the 
uperalivc pnnvduivs for them. 

M''(ian'/jt ij/ Ihf StmiU Intestine. — Ttie wounds of the small 



I 




OPERATIVE TECHNIC 



2S5 



r 



I 



latestine. much more exceptional (two cases in 200. Segond), are 
generally caused by the freeing of the very adherent adnexa and 
are only met in very complex cases. 

Peritonitij'. — ^Septie peritonitis is the most serious of all the 
coui plications which come on after vaginal hysterectomy. It in 
the habitual <'au9e of death after that operation and one can say 
that the |>ercentaj;e of deaths after vaginal hysterectomy practically 
denotes the number of cases of peritonitis following on operation. 

This c<>ni plication has Ijccome rare and is l»ecoming rarer. 
The relative benign character of vaginal hysterectomy from the 
|)oint of view of infection may ciiuse astonishment when one thinks 
tiow difficult it is. despite the precautions one takes to artificially 
unite the o|H'rative field from the side of the abdominal cavity. 
This fact explains precisely that in grave cases where suppura- 
tive lesions exist, the pelvic cavity is isolated by aclhesions from the 
large peritoneal cavity: it is explained also by the large ojien 
drainage route of the vagina.,' As we will have occasion to see 
further, in studying tJic septic }>eritonitis following on celiot- 
omy we are almost disarmed, surgically s|)eaking. in the presence 
of this complication. 

Iniexiinal Orrlu8io}i.—'V\\\» usually results from an adhesion 
of the intestine at the vaginal cicatrix and appears at a variable 
epoch after the operation. One may in these cases of precocious 
iKX'lusion liberate the intestine by mani|ndations through the 
vagina. This is most often accomplished by the establishment of 
an artificial anus, or by a eolotomy followed by freeing of the 
adhesions. We have seen after a simple fistulation of the intes- 
tine, all the occlusion troubles disap]>ear and the fistula close 
it|ionlaneou8ly afterward. The method of action ap|K'ars to be 
indicatetj in certain cases, where the general condition contra- 
indicates a more serious intervention. 

Eschars. — Sometimes these appear as sacral eschars in 
women having undergone a vaginal hyslcriM-tomy. TIie.se are 
said to be lesions of the trophic order. We think these bed- 
sores are only macerations of the skin, and since that we have 
lost fear of moving the patients in order to secure for them the 
iiecess-iary attention and <'leanline.s.'i this complication has com- 
pletely disajjpeared from our wards. With appropriate dressings, 
these eschars heal rapidly. i 




2d6 



VAGINAL HYSTERECTOMY 



2. Various Procedures. 

Doyen's Procedure. — We will not insist on the procedure of 
Doyen. As may be seen, it rests on ttvo runilanientnl principles: 
rejection of all prffentive hemostases^ vifdian anterior hemisection 
in order to perm it the uteruK to be lilted forward. ' _ 

We will confine ourselves to remarking that Doyen lirinjrsw 
about the hemostasia of the broad tiganient with a single pair of 
verj- lonj; elastic forcei« which he applies from above downwani 
along the extent of (he broad ligament, (jcnerally he places ii 
Kccontl n-infoi-einji forceps inteninl to l]ie first [lart. We prefer 
the lechnic we descril>ed previously in this book. In cases where 
Ihe adnexa are difficult to get at it will be? well sometimes to 
continue anterior mediiin hemisection on the posterior face as 
far as the cervix. Kach half of tlie uterus attached to its b, 
ligament is more easily drawn out. 

Pean's Procedure. — Preventive b>r<'i pressure am] morc«.*IIe- 
mcni are llie two principles of Pea n. This procedure is done in 
the following manner: A circular incision disinserts the vagina. 
Then free by separation the two faces of the uterus and bn>ail 
ligaments up to a certain height, more or less extensive. Apply 
forceps to the liberated ]>orlion of the ligaments which are cut 
through internal to the forceps. The fragment of uterus lil>- 
erated by this partial .sectitni of the Itroad ligament:^ i->i then 
divided with strong scissors into two portions, one anterior and 
the other posterior. One forceps is placed at the base of each 
|)ortion and the segment of tlie uterus placed below the forcei)s 
is exciseil. The same procedure is re|>eated on the portion of the 
uterus that lies above. Each stage may thus In* divided into four 
principal parts: I. The freeing of the anterior surface of tlic 
uterus from the posterior, 'i. The clani])ing and section of the 
broad ligaments. 3. The division into two portions of the por- 
tion of the uterus freed by the preceding nmnipulalions. 4. 
Tlie excision of the two portions thus obtained. We thus obtain, 
by succc-vsive stages, the complete excision of llie uterus. 

The most im|H>rtant point is never to cut through a segment 
of the uterus l»efore placing above it another traction forceps in 



I 
I 
i 



1001, T. LXIII, p. I J 



median ixulprior tinniwrtion of (li« utrnix. lArrJi.f. tipt^ 




VAIUOL'S PROCEDURES 



257 



order to preserve always a solid hold, witlioiit wliioli the fundus 
of tlie uterus may sharply disap]>ear into tlie depths and froni 
whence it could only be recovered with great dilfi<;ully. 

Wc must never go away from the median line in the holds wc 
tnke in order to uvoid false holds, tears, hemorrhage and wounds 
of neighdoring organs. 

Segond's Operation. — ^It may be summed up as follows 
Segond commcnreA the kijstcTectumti like Pean and finishes likt 
/}oyen. He commences really by excising the cervix; lo do 
tlii^ he clamps and cuts (lirongh the h>wcr ]>ortion of the broad 

iment, isolated at first on each side of the cervix from the pcr>- 




Fio. 230.— Hofeolloment of tho iitoru* [J. L. FauT»). 
Uterine li-ssues (interior ])orlion of the broad ligament with the 
Uterine artery, interior portion of the utero-sacral ligament of the 
same side). A short-bladed forceps seizes the tissues on each 
side of the cervix and a single cut of the scissors divides them 
between the forceps and the cen'ix. \s the descent of the uterus 
is often limited by tJie utcro-sacral ligaments, when these are 
lecUoned across, the uterus descends some centimeters and the 
operation is facilitated. 

The cervix is divided into two portions, one anterior and one 

IT 




256 



Doyen's Pr' 
Doyen. A;^ i, 
rejediou »/ ni 
in order In f 

We wii! 
about tilt- li- 
very Ifinj; '■ 
alon^ {he ' 
secoinl II : 
the tcclii'- 
the iidiii 
coiitiiiii' 
far as ! 
ligilltir 

Pe 

men I 
the f. 
Tli.-i 
\\\i,u r 
fore ■ 
thn 
er;: 
ih'^ 
Ih. 



7.i.~ iK'ing done, the 
.. ._ -- r'undus descciul hy 
■ -he anterior nail or 
f :hat wall. Set;oiul 
.. :.;rv amputation of the 
him, the best means 
,:■- of the ureters. 
V':.> the.se two surfjeons 
.,-:/ median scdinniiiij 
-.ednres of Queuu ntid 




-■■.,- .lr;iw 'loivu mill nut the Iw.i Icilv.- 
. ■ -V 

. u-^risection is done at the end of 

^, ^ inh has been Iil)erate<l, Inis cK*- 

, , ■■.:« Tiiaueuver, destined to facilitate 

,-.^.1 ::cauients. It i-s based on the 

. . ;ie -ittvnd broad Hfjament is always - 

■■f ir>t. 

- ■(. KV.iiseetion is to enable the oriran* 

.;., i. This maneuver is carried out at* 

,;»iuiii a.> it is done in Doyen's anteriot* 

.,>^ trrt vn upon by forceps, doe.s not s(— " 

.j..ii .w :n the median anterior section, lui 



VARIOUS PRtKEDUKKS 



259 



open itself out, to sink ui>on itsell", so lo speak, in the medinti 
line, in descendiufi in the axis of the pelvis (Fig. iii7). The more 
Ihe two segim-tiLs sfpiimle in (liverjfence. and tlie more the fundus 
descends, the more does one continue the median section toward 
the fundus (Fig. 238) and ovciitually hy fresh holds anil successive 
sections of the uterus to completely divide it into two. The rest 




Fui. 238. — While Tli« liemlseotloii tul- 
vaneM khiI the two hulvci o[ the utcrua 
MfNU«te tho (undu* iJc»c«Dd« and comes 
dvwD to Uie rulv*. 



Fto, 239.— One of the halvM or the 
utcrufl lutH linon piiiihni bnok into tha 
jM'lviK Bsd thin )>ennlu of ibo more vuf 
descent o[ rhe other. 



of tlie u|ieralion with relation to each half h continued as iu the 
procedure of Ooyen, the section of tJie uterus has been carried 
out through the cer\'ix. posterior wall ami cervix. It is at times 
of advantage when the median .section is finished to pre.ss back 
one of the halvta into Uie |>civis and thus render the drawing down 
of tJie other easier. 

J. L. Faure's Procedure.— If Ihe uterus does not come down, 
even after total hemi.seelioii, the fundus of the uterus n-niains 
immobile in the pelvi.s; then we may sometimes get at the uterine 
comua in resorting to Pcan's morcellement, and in practising 
tmn^ttfrrse segmerttalion of Uie iiterua. After the median .section of 
a part of the nlenw, if one does not gain any more ground, one 



260 



VAUIKAL HYSTIiltECTOMV 



shouUi flit across one of tlic halves of tlic iitrnis. Tlie scRtnont. 
constituted by the se;;meiil thus cut ucmss. separalt-s anil with a 
forceps introduced from above upward alonj,' the length of the 
uterine border one is altle to seize the upper portion of tlie broad 
lipnnicnt up to the comu of the uterus. With a pair of scissors 
detach tliis uterine cornu from its insertion into llie broad liga- 
ment, and the mobilization of the uterus enables us to conchide 
an oj)eration which appeared at first to possess insurniountuble 
obstacles. 




Flo. 340.— TratiBvcne veniou of Ihr iitC'rus after linmii«ctian. 

Ligature of the Broad Ligaments. Angiotripsy. Galvano- 
cautery. — All the procedures we have described have in common 
the liemostasis of Uie broad ligaments by means of a forci pressure, 
which is allowed to persist during a certain period of time. The 
ligature of the broad ligaments is generally n-jVcted save in cer- 
tain exceptional cases (hysterectomy lor prolapse). 

Even in Germany, where for a long time fer^'cnt operators 
opjMMcd it, they Iiave now accepted forcipressure. It is not 
without drawbacks ami the clamps left in for forty-eight hours 
interfere considerably with the comfort of tlie patients. Tliis 
has inspired certain surgeons (Doyen, Tuffier in France, Tliumin, 
Amann in Germany) with tlie notion of applying ttnijwtrip.ty 
to vaginat hysterectomy. Although this has been successful, it 



I 




OPERATIVE MOni>"ICATION8 



I 



U nol without danger; tlicre has been persistent oozirif^, in fact 
veritable hemorrhages or even jjeritoneal infection liv flic falling 
back into Uic uUloinen of tlic [M-dicle.s which are no longer held 
in the vaginal wound by ligatures or clamps. It is gpiierally 
admitted that ittsinipnidcnt to apply it without adding "ligatures 
of safety" and without closing iijj tlie peritoneum above the 
stumps (Doyen). \Vc arc [)rceipitat('d thus info the position of 
tlic incouvenieiice of ligatures and operative cumjilications. 
Also, in spite of the cnlhusiHsin excited at first, nngiotripsy is 
hardly ever employed as a means of licmostasis in vaginal 
hysterectomy. 

The employment of tlie ijalvatio-eautenj advocated formerly 
by Byrne for amputation of the cervix, has lieen recently put 
forward by Werdcr for hysterectomy in cancer; one avoids, by 
these means, all local recurrences. The vaginal mucous mem- 
brane is incLsed around the cervix %vith a galvano-eautery at a' 
dull red heal: tlie fornices are ojwned: the uterus is tilted forward; 
and downward clamps are placed on the broad ligaments which 
an- afterward cut across. The uterus being lifted out, the broad 
Ugamentsare drawn on and then external to the forceps, Downes' 
elect r«-lliermie clani)>s are a[)plied. These ernsh llie tissues like 
an angiotribe and then cauterize the crushed parts.' All the 
bleeding {joints of the wound are cauU^rizcd and recauterizwl. 
Conclude the operation by suturing the retro-vesical peritoneum 
to the po.sterior |>eritoneum of the poueh of Douglas, leaving on 
each side a s|mce, in order to insinuate along the stump of the 
broad ligament a dressing of iodoform gauze, which is taken 
out at tlie end of four or five duvs. 



I 



3. Operative Modifications According to the Nature of the Lesion. 

1. Vaginal Hysterectomy in Cancer.- >'aginal hysterectomy may 
he done either for cancers of the cavity of the uterus or for cancers 
of the cervix. In the latter ea.se, it is better to do a preliminary 
radical curettage, removing all the cancerous vegetations. 'I'he 
curettage- shouhl he done innnediately before the hysterectomv, 
may I>e several days Ijef ore, when clinical symptoms lead one to 

' CAiiUiiEallon X*. oliluinud l>v ihv uFlioii of u Imnd uf pluliniim which U dotililm) 
orcr one of the Ifladi-n of \\n: fxr'---; .> and krpt rciti witti un rUctric current. (Davow, 
Ann. 4f Gytue.. VMl. T. I. [v :i.'.:> j 





.X2 VAGINAL HYSTERECTOMY 

think that there exists a serious degree of infection of the can- 
Ltjrous vegetations. The preliminary curettage has a double 
idi-ajitage: it permits us, first, to secure a possible disinfection 
oi the opentive field to a degree unknown of any antiseptic 
■«.'iuuoQ:s. [t ha* the advantage of facilitating the clinical ex- 
ri«-'«rion and of enabling us to appreciate with more precision 
r!jjj3 '.•'t the bimanual examination the degree of extension of 
rje ■Kv'ciitjai and of seeing if a radical operation is or is not 

Vj^-ItaI kvstMvctoniy for cancer would not have the preten- 
-ici; ,'C 'vl:«: * radical operation if it only attacked the primary 
'\v',;.s. »*A»»iitt Krtnc concerned with the lymphatic vessels which 
Arv acvtv 'rvyjaonUy invaded. 

I; y^Nilvi iv «>nducled in such a manner as to excise the 

o'ic-.:x' ;'rt:tu::w f»H-u* and to avoid the grafting of the neoplasm 

.tn '.iw ru* surfaces. This double desideratum dominates the 

^•tvr»:x»e tv\'ftu(»" in t'ases of vaginal hysterectomy for cancer. 

It :t tis » question of a cavity cancer, circumscribe the cervix 

^^ itii ;t>o v»r\iiuar»' incision. If it is a case of cancer of the cervix. 

.»v<-t;ii:v ca-"*'. i.vuuuemv by the dissection up of a little vaginal 

.viJar. «!ui.li is prudently detached anteriorly from the bladder 

AIM iNv-^t-riorlv frvnu the rectum. Commence the operation by 

■uviH;; the bhuKlcr, U-cause the invasion of this organ should be 

■»X»»i''*'^' -'^ •*" of'erativc i-ontraindication. In order to find out 

iu- xiatc I'l the bJadvler, crMumence by a lateral in front of the 

lusui It^iitmciits. Move the band gently toward the median 

!uK-, 'i ;tt tliis U'vvl one finds friable tissue, stop. To pursue the 

..is.-i.iiKni «oiiM k'nd to the formation of a vesico-vaginal, in the 

tAwiUA- .>( «lu«.h one niisht lio[>e for a relatively durable result. 

l! ;fu- MavUicr is rviv^rnize*! as healthy, proceed with opera- 

,s-ii 11 v)^^-!^!!^; the rwttwiterine cul-de-sac and conclude by 

..i..;u'! 'K'iui.'Ntx-tiou pr^KtHlun-. following out the technic we 

i..^v uJvMvI> irKli*.-«t»xl. In these particular cases of cancer of the 

V. ».\, ■vxv'iHi'^ f.t>.«.-\\tur»> biis the advantage of removing from 

iK ^vi.uiNv nAd tttcvt»nivr»ms mass which may infect the tissues 

\ V viu-ialK -.viKitic*! that the removal of the adnexa should 
V .v...v-vi ^'li' \v«u.'**' cases have Ijeen reported of metastatic 



OPEHATIVF, MODIFICATIONS 



203 



e immediate results an- tlu' fallowing: 

In 8156 cases collected bv Richot there were 175 deaths or 8 
to 10 per cent. 

The opcratiott does not therefore present an extreme gravity. 
Unhappily the later results are more mediocre. In F. Ferrier's 
work the recurrences have been 70 per cent. ; according to Zweifel, 
65 per cent, and Olshaiisen, 01 per cent. 

The recurrence is above all in the first year that follows the 
operation; the frequency diminishes prndually as the inten'al 
lenfilhcns. as the following table of recurrences <-ompi)ed by 
Segoud shows: 

The recun-ence occurred 14 times in the first year. 
^^ The recurrence occurred 9 times in the second year. 
^^M The recurrence occurred 5 times in the thin) year. 
^^H The recurrence occurred times in the fourth year. 
^^V The recurrence occurred 1 time in the fifth year. 

■ After five years the cure may be regarded as certain. Hut 

I Segond observed one recurrence after seven years. 

W The recurrences are almost always seen in the vaginal wall, 

near the scar in tlic cicatrix itself or a Httlc above it, probal>Iy due 
fc to Uie implanting of cancerous grafts during excision. These 

local recurrences in<hiced Werder to resort to excision by galvano- 

cauterw 

* 

i. Vaginal Hysterectomy in Fibromata.— This is often done 
for fibromata. We will see that it loses ground more and more 
and teufls to Ik- replaec<l in the majority of cases by abdominal 
hysterectomy. 

One point dominates all the Icchnic of vaginal hysterectomy 
for fibromata: it is the great importance of, one might almost say 

L imperative nature of. morcellement. 

' Tim mi>reelh'mcnt has a double end in view: To diminish 
llie volume of the tumor and to permit it to pass through the 
vagiiml tissues and reduce the uterus to a flexible shell, so to 
speak, which will tilt forward as in the way a uterus of normal 
dimensions does after a simple iinlerior hemisection. 

It is evident that the nuiiiipulatioiis which give this double 
result may vary according to each case. Some smaller fibro- 
mata, easily accessible, may be torn out with the first pressure 



264 



VAGINAL HVSTEHECTOMY 



applieil to the traction forceps, which seizes them and dn 
U|K>ii them at the same time iiiipartinn to Ihem a twist. If the 
filiromala are lar^r. more solidly attached, then we would resort 
to morcellement witli the bistoury or scissors, aiding ourselves 
as required hy the corkscrew and ovaeualing conoid-shai>ed 
masses of tissue. If the fibromata are situated high up and 
inaeccitsible, we conuiu-nce by excising ii V-.sliHi>ed area of uterine 
tissue. (See before, morcellenient in vaj^inal myomectomy.) 

The utenis is attacker! on its anterior surface. The anterior 
wall is resected over a more or less extended area: tliis resection 
admits of successive enucleation of ditfercnt tibromatous masses 
witli or witliout morcetlement. 




Fiu. 341.— Hanwllcmonl of tlw antcriur (ace of the uieruti (I>aytii). 1h» 
I. '1. 3. elc, kn; HucooMvcly «xoiNcd. 



The jtenend shape of the resected area i.H a \* witli the sum- 
mil U-low (Kijj. iil). 

In lhe.se manipulations then> is never need to excise a frag- 
ment of the mass without having as preliminary placed a traction 
forre|vs on the pari inime<liately above. 

In a general way tlie conuneneement of llie operation is 
diffieult; U-giiiniiig by removing ven,' small pieces, one procx*eds 
to gn-ater and greater. At lenglli we have a uterus emptiwi of 
all the fibromata it contained and of whicli the' anterior wall has 
in a great tueasure disapiH-areil. Nothing is simpler tlian to 



I 



OPER.\TIVK MODIFICATIONS 



205 



lever up tlie uterus and (hen apply forcipressure to llic broad 
ligiiincntii us usual. 

This method of prot-edure appears to !«• su|>eri(»r to that in 
which the fiIir<una1ou.s uterus is i-csected Iiy successive stages, 
with forcipressure and preiirainai-j' section of the corresponding 
portion nf Ihc hroad li/^iinienls. as In Pean's operation. 

Ill 13(i!> vagina) liystcrecLomies fur fibroma, Kiehelot had QS 
deaths, giving 4.6 per cent. 

Segond, whose experience and skill in vaginal surgery is so 
well known, gives results of 15 per cent, of deaths in vaginal 
hystcrectuuiy for fibroum. 

'ITiese differences may be explained by the fact that Segond 
pushes lo excess the vaginal ojierative route ami thus in attempt- 
ing very diflicnlt cases acquires a higher mortality. 

8. Vaginal Hysterectomy in Inflammation of the Adneza. — 
It is known that Pean regarded the excision of the uterus as the 
essential stage in the treatment of influinnialions of the adnexa by 
the vaginal route. We excise, to use his expression, "la bonde." 
the bung literally wliicli closes the suj>purating |M'ri-titerine 
]K(ekets; Uiese being freely drained by the preliminary excision 
of the uterus, heal perfectly without any call for their individual 
cxtir|iation. This is a mistake: we have on many occasions 
excised the entire uterus without opening any peri-uterine sup- 
puriilive foci. For this rea.s<iii, niudern surgeons pri'fer to excise 
the disea.sed adnexa with the uterus. 

It is certain that this excision is diflicult and often even impos- 
sible. But systematic attempts at excision, even when they fail. 
have tlic advantage of pn-venting a .suppurating focus, remain- 
ing uno[»ened in spite of iJie e.\cision of the uterus. 

In excision of the atlnexa (hiring vaginal hysterectomy, free 
these by the hand. They are separated behind Uie posterior 
surface of the broad ligaments, and we then endeavor to draw 
them toward tlie fundus of the uterus, fturgeoiw with knowl- 
edge of the vaginal route generally succeed in the extir]>ation in 
the majority of cases (Segond, 55 times in 77 cases; Bouilly, 
45 times in .5^ cases; Jacobs, STi times in 4^1 cases). 

The immediate results of vaginal hysterectomy for diseasetl 
adnexa are the following: In ] 113 cases collected by Hartlenbeuer, 



■Jfjf. 



t\':'JS\l. Hl'STZiEirr': MT 



tjf-- ':^. S^ '>ftcK.*. ^^mz atimt 3^ p«f erat. Putimlar statistics 
2:-.* *:. *T*'ra.2»' njortatitv ^tizhth* hieiier. 

Rlri^fA. $/f7 OfjieratioD£. 1-5 deatk: -L.ST prr cmt. 
7T«^>-,rid. ^rXl operations. 14 deatbs: 7 prr crat 
Hf:jnlf:T. -S^ Operations. 6 deaths: II per craL 
Brfriiilv. 51 c^raticMis. 3 deaths: 3.5 per crat. 

1. Hjrstercctoi^ m Pnapeial lafectioa.— The puerperal 
'j!>TTi.- i'> ren' friable: iU cervix tears under tiactiao of toothed 
i<»T':*:\r>!, which are iLsuatlv employed for the drawing down of 




1 1';. 242. — I'li'^rpirral hy^.Utiixxniay. The friable utenu is sciied vilh cyvt forceps 

'J. L. Fuure;. 

tlic uterus. After successive liolds the cervix is lacerated. 
IxriroiiHrH iiiir(K;ognizable and unfit as a hold in order to do 
\\it: <»jt4Tati()n. All these inconveniences disappear if, as J. L. 
Fiiiin; advises, one uses broad-bladed c}'st forceps instead of 
t.Iie tootheil variety. Tlie larf;e hold prevents the cemx from 
tr>aritif^. In women reccnlK' "accoucliees" with a large vagina 
iiiid a supple uterus the ojM'ration is of the easiest if one draws 
^I'lillv- ()ri tlie uterus without force. The uterus flexes forn-ard 
with tlie j,'n'atcst facility and the operation is terminated very 
rapiflly. 

'>. Vaginal Hysterectomy for Prolapse. — ^Vag^oal hysterec- 



OPERATIVE MODIFICATIONS 



267 



Tny is rarely practised for i>roia|>se; it is only esceptionally 
imJicated in the tn-atment of tliis HlR-ction. 

Thf tcchnic of liyslercctomy in tln*se cases presents some 
IKTuliarilies by reason of the special anatomical conditions we 
Rad. 

1. The replacing of continuous forci pressure by ligatures, the 
broad ligunient.s being, as the result of the drawing out of tlie 
uterus, very accessible. 

3. The necessify of making at the same time as an excision 
of llie uterus a large excision of the vagina, since this canal under- 




.'■■fl«->~- 

Fio. 843,— Tlic [iiiitfrior ilontidation imocd (Awh). 

goes a. considerable increase in size as the result of the prolu|>sc. 
Fritsch's Procedure. — To do this ojieralion draw strongly on 
tlic cervix uj>ward and forward. A V-sha|)e<i incision is tlien 
made with the summit pointing posteriorly at the level of junction 
of the [H>sterior third with the anterior two-thirds uf the pos- 
terior vaginal wall (Fig- 443). The pouch of Douglas is opened 
and the fM'ritonetim is sutured to the ]>osterinr lip of the incision. 
is then easy to draw the fundus of the uterus into the wound. 
broad ligaments are tied otT in stages commencing from 
above, and removing if possible the adne-xa. It only remains 
to separate olT the bladder and to resect the anterior vaginal 
wall. 






2as 



VAGINAL HVSTERECTOMV 



The cer\'ix is now strongly <lrawn downward, iiiicl a I'-sliaj 
incision is made in the vagina with the couvcxity corrcspondinjj 
lo the unrter (I'"ig. 244), an<I the mucous membrane is separated 
up from Uiis almost tu the cer\'ix. This is done partly with a I 
scaljjel and partly hy the finger. This stage of the o[)enition 
is difRcuU, esjjeeially wlien anterior eolporrliaphies force us lo 
work in cicalrieial tissue. 

Once tlio cervix is rcaehwi. we may operate from aliove 
downward bv the vesieo-uterine cid-de-sac. If the adliesion to 



ril 



m 



t m 



■;?- 



Fid. 2t4.~Tlt«unl«riordmuiliilloii Iraetd (AmJi). 



the bladder Is too firm separate oif a thin layer of uterine tissue. 

The uterus having lieen exei.sed willi the two lai^^e anterior 
and [wsterior flaps of vaginal mucous membrane attached to it, ■ 
the two Ii|« resulting fn>m the res«'rtion of the mucous mem- 
brane of the anterior wall of (he vagina are united transversely: 
tlien, after having reduced the hhidiier, il is covered over again 
with vesico-iiterine [icrilonoum which is sutured to the mucous ■ 
membrane of the vagina. Further, the |Kiticlcit of the broad 




OPERATIVE MOniFrCATIONS 



269 



ligaments are sutured to the vagina on each side and thus keeping 
it in suspension. 

The non-oblilenited peritoneal cavity is tamponed with 
iodoform gauze. The opiM-ation is conchided with a recon- 
slruction of llie perineum. 

Doyen's Prvcedure. — ,\(!ting on the observation that the 
pouch of Douglas is always easily acwssihle when the inferior 
border of the bhtdder is sometimes difficult to make out amidst 
Uie hy])ertroi)hied and indurated tissues tliat surround it. Doyen 
commences by opening the peritoneum posteriorly. lie cuts 
acrats Uic mucous membrane trans vcr.se ly at the level of the 
old posterior fornix of the vagina. As soon as the li[>s of the 
mucous membrane o[H'n out, he makes in the median line pos- 





Pio. 245.— Totality of ojtciiiwl pari* (Aseli). 

leriorly a longitudinal incision which opens the inferior portion 
of the pouch of Douglas. After enlarging the jwritoneal open- 
ing with the fingers, he hooks up the fundus of the uterus and, 
making it lilt forwar^l. he draws it outside. 

A longitudinal hemisection carried out on l]ie posterior 
as|K.*ct of tJie uterus is continued on to the fundus and then on to 
the anterior as|K>ct. The uterus and bla<lder arc separated 
with the finger or a blunt instrument and then after com]>leting 
the hemisection the anterior loniix is opened. The circum- 
ference of the cervix is freed by the dissection of a collarette of 
the vagina. The two halves of the uterus arc now only held 
by the broad ligaments. 

After giving each of these halves a torsion of 180 degrees. 




270 



VAGINAL HYSTERKCTOMV 



of a spiral 



imparling lo eat-li hroml ligaiiu'iit lh« appearanc-e 
cord. tJiese cords are crushed, ligatured, and cut below the liga- 
ments. Then he closer by a purse-string suture, which in pass- 
ing through the broad ligaments, takes up the |)cnloncjil cuihir- 
ette. He excises the largest part of the anterior wall of tlic 
vagina and di>es an anterior culporrlmphji' and concludes with a 
col po- perineorrhaphy. 

Iteitull.a. — Considering the weakness generally found among 
patients operated on for prolapse, the hysterectomy gi\'e,«( a 
fairly elevated mortality of live deaths in .57 cases we have 
collected,' which number is a little higher than liiat given person- 
ally by Kirchgcssner. who in 40 cases lia<l three deaths.' 

The later i-esults. if one is confined to the excision of the 
uterus and of the vagina, have been mediocre; it has also been 
found necessary* to add drastic {jcrincul operations to the excision 
of the uterus. 

In these conditions it is understood that we reserve this 
operation to tlie eases where a lesion of the organ exists (gangrene, 
fibroma, cancer), which suffices in itself to render excision neces- 
sary, and to those cases where the uterus is constantly external, 
extensively ulcerated, and is the origin of various discharges, 
mucopurulent or sanguineous, and in women, either at or jMist 
the menopause. 

6. Vaginal Hysterectomy in Uterine Inversion. -The o[iem- 
tive technic differs according as whether inversion is incomplete 
or complcle. 

In incomplete inversion seize the cervix with two tra<rtion 
forceps attached at the level of the comniiiwureK. Circum- 
scribe the cervix with a circular incision, penetrate the posterior 
cul-de-sac, then explore the pelvic cavity and determine the 
anatomical disposition of the uterus. Then pass to the libcnitiou 
of the anterior part. 

Split the wrvix in the nie<lian line anteriorly. Then ace if 
that incision is not sufficient to secure the reduction of the in- 
version of the uterus. If the reduction is impossible, continue' 
tJie o|>eration by opening the anterior cul-de-sac. Nothing it^ 

' H*rUDutB ftod du BcKiehcU VuitiAl UyMereotomy In Treatawnt o( UUrins Pf»- 
kpM. AntMkt lit nra.. ParU. ISM, T. 1. p. I-V 

*ni. tQiehnHDer. Complete Vuriiud Ivxiinwtion in Cotnpble UUriua l*n>luM*. 
Xfiuehr. f. Ort. «. Oyn,, Slutlsad. 1»6. T. LVIlI. p. — 



4 



^ 




OPERATIVE MODIFICATIONS 



271 



simpler than tviiig or scizinf; the broad ligaments in a pair of 
forceps and of sej)arating off tlie uterus. 
P IF the inversion is complete, the commencement of the 
hyslereetoniy may be delicate. Do a circular incision at the 
level of the cervix, which may l>e detenninc<l hy palpation. 

Open the posterior foniix as soon as the peritoneum is 
opened, introduce the finger into the peritoneal cavity and 
draw- it in front of the e^^rvix. Then with the finj^er open Ihe 
anterior fornix cautiously. When the uterus is freed ante- 
riorly, tlie oj>era.tion may ije pursued witliout difficulty juh in 
incomplete inversion. 

7. Vaginal Hysterectomy for Juxta-uterine Tumors.— \'agi rial 
hysterectomy may be done during the course of an operation for 
excision of a juxta-utcrine Innior.' 

Two cases present themselves: Either the tumor is supra- 
uterine and the hysterectomy is done in order to create a way 
of aoce.'is; the kyaterectniny is then S|)olccn of as ftreliminari/ or 
the tumor is rather more intrauterine and its excision mav be 
carried out witliout a preliminary hysterectomy. Hnl this 
removal leaves a denuded uterus, badly fixed, and the compU- 
mcntanj hysterectomy is re<piired. In the latter case hysterec- 
tomy has tlie advantage of creating an extensive drainage canal. 

In spile of some successes obtained with this manner of 
operating, relative successes really, since Segond had two deaths 
in twenty-five cases, making a mortality of 8 j)er cent., we believe 
that tlie abdominal route is less grave and .should be done when- 
ever we are in the presence of tumors, manifestly of the adnexa. 
liowcvtT .small they may be. We must apologize for the long 
dissertation on vaginal hysterectomy. 

Hie great place it has occupied in the history of gynecology 
justifies the developments we have consecrated to it. Wiile con- 
rinceil jmrti-sans of the abd<uninal route in the immense majority 
of cases, we believe that vaginal hysterectomy may still lie of great 

rice in particular cases. 

In inveterate uterine prolapse with extensive lesions on the 
cervix, in certain cases of irretlucible uterine inversions, in rare 
acute or virulent )>e]vtc suppurations, where colpotomy is insuf- 

' ScRniul. IUl>l«nl Tumon of the Adnexa that *re Suitml for ExciMon by tho Vkipiu' 
Itaule iim nyilcr«oU)my. Revn* <U yj/nMulogie, Pan*, 1897, ]>. 205. 



272 VAGINAL HYSTERECTOMY 

ficient to arrest the march of invasion of the disease, and in 
puerperal infection, vaginal hysterectomy preserves its superiority. 
It is even indicated in certain cases, ordinarily justifying the 
abdominal route, when, for example, the patient is very stout 
and the uterus is small, mobile and may be so easily extirpated 
from below. 

The annoyance to the operator of adipose excess of the 
abdominal wall, and the difficulty of obtaining a quiet anesthesia 
with regular breathing are strong arguments in favor of vaginal 
hysterectomy. 

We will not insist on the choice of procedure as it depends on 
the case; that which we have already said in reference to each 
enables one to decide what to do without our returning to the 
question. 




^*^Vard Uie vagina and in exposing to the light of day the whole 
^'^■pna am! its fomices. Before Schuchardt vaginal incisions 
splitting were adopted. Imt these had no connection with 
ichig paravaginal incision, of about 18 to 20 em. length, which 

' K>ri Sofaiioliardt, COncertiiiii; tlitr I'liruvni^iniil MoTli»r| of P.xtirpntinit tlio ri«<rua 
»M lu RMultii in Coneer uf Ibe L'Utu*. Arch, fur kUn. Chir.. Btrliu, lUOl, T. 
UlV. p. 38». 




274 



HYSTERECTOMY BY THE PARAVAGINAL ROUTE 



runs along all the whole level of the |>enneuni and exposes vc 
largely the liroad ligaiiicnl. ' 

By this route it is possible to freely resect llic vagina anil th 
parametrium after dissection of the ureters. Adopted b 
Schauta,' this incision has Iwen eulogized in America by Gel) 
horn,' in France by I'roust.^ and in England by Sinclair.* 



FlO. 217. — Tliu circulur va|:inul eutl Ii&a brvii <litM'«1<Mi u|). il '1. and tbe aitlu 

kept long, .Vina tlir pnravnginitl incision is oui im: <j i louit). 

Operation. — Schauchardt makes an incision commencing e 
the left labium major and going through the left part of t)i 
vaginal canal. From there the Incision tends to approach lib 
median line, while avoiding tlic rectum and sphincter region. 




* Promt. Totnl Cotpohyricreoiotny bj- the Vulvu-fwrinettl Route. Prat* mAtifA 
Pkriv, Mkfch 1«, 1907, 

* SuMkir, On Fanvuginii] S«otion. Jovmol cf Ottl. and O^. of Briiith £■■; 
l.olidoii, April, IflOK. 




UPICRATIOX 



275 



Schauta added to it tlie closing of the vagina in such a manner 
aH to remove the cancur without any fear of infection uf the 
ojjerative grafts. Proust, who has published averj'good technic 
of lliis operation, descril>c.s it fts follows: 

Circular Separation and Closing of the Vagina. — After cau- 



\ 



1. M8. — Tho pliraviigid/U rii|,ii.ii linviin; 
iprly. On comparinii i!ii- Ii^ue.- with 2jY, 
I pvm bj Scbaiitu'H Incibioa U'i^uot). 



Ti'ii rii.L' I 



iilijm is iiiBi'rliMi 



I 



tom^tion of the neoplasnt and clisinfcctiuti of the vagina, a cir- 
cular incision circumscribing either the middle portion or the 
inferior portion of the canal is done (Fig. 240). A circular cuff 
r>f al>otit 5 cm. long having been dissected up. the vagina is 
liennetieally closed with sutures, which an- kept long so as to 
»T\e as agents of traction. 

When the .suture area has slopped bleeding, the surgeon 




276 



HYSTERlXrroMY BY THK PARAVAGINAL ROUTE 



change!! his gloves and instruments in order to carry out the] 
antiseptic stages of tlie oi»crtttion. 

Paravaginal Incision. — The paravaginal incision commences' 
more or less high at the level of the inferior lip of the circular 
incision of the vagina and at the junction of the posterior and 
left lateral (juadrantt and from these it is directeil towani the 
vulva, which is also cnl through at the junction of its posterior 
and left lateral |Mirts. Then it is prolonged directly ^iNickwardJ 



Fib. 240.— IJbemtioDof thelaUr . 



<i'fi>lIBt). ^m 



and Ifttorally, hut parallel t<» the axis of the perineum and ter- 
minates external to the anus. It may iKM-arricd <in to the sacrum, . 
and I)e<'onio cfmscqiiently i>anirwtal (Fig. 247). 

The incision pusses through all the thickness of the soft 
parts of the perineum; it cuts through the tunnel of tlie levalor 
ani near tlie rectum, hut s|>ares the sphincter and the intestine. 



I 




OPERATION" 

Tlic rectum Is iKoluteil and inclined toward the right. The 
vessels are lied and the wound tamponed with stfrilizcil (fauze. 

Ill cases particularly difficult we may, after Staude, make 
a double |>arava|;innl incision.^ 

JJiistvlion of the Itlmlder and Vretera. — The separation of the 
libdder is done as in anterior colporrhaphy ^nd in tilling the 
uterus hat'kward. 

The 5e[>aration becomes very simple when one arrives at the 



■<a. 320. — Th^ anieiiut fH:riioii«il cvilHle-)<uc is ojii-iioil nnil ihc iiiinis tilted anteriorly: 
tli« opemlor pMtstx a Miliire in unlcr lo lie tin- rumid lieaiiicrit il'ruuM). 

Height of the cervix, in front of which is a lamellar, cellular 
Ussue. Of course if there are neopiasniic adhesions at this level, 
U is a ditferent question and one may be ol>Iij,'cd in such circunt- 
stances to do a partial resection of the bladder. 

Once the bhi<l(ler is se|>arated in the median line, we pass on 
to Uic isolation of its lateral an;;les "veritable cornua which 
continue with the uterus." liecognizable by their reddish color, 

' SUude. Ucber (olaloxotiriuition drr oarcinonuitosrn Vtcrus luitti-U doppelMlluKr 
SdMUcmiMUNng. Mon./. (M,. und Oi/n.. Berlin. 1902, T. XV, p. 663. 



278 



HYSTERECTOMY IIY THE I'ARAVAUINAL ROUTE 



they run toward parainetniini uiul llicir isolation Irnds to 
ureter, which runs obliquely backwai-d and milward. like u coi 
running into the l)a.se of the hroad ligHinrnt. In .some cnscs o( 
has liad occasion to dissect out the ureter lying in a p^tove j 
cancerous tissue. In order to follow tlie iHsscction of the ureta 
sufficiently far back, it becomes necessary, when their situation' 
recognized and llieir isolalion coninienced. to free the vapiij 
Freeing of the Lateral liordcrs of the Vaffina and Disstrtion 1 





l-'i(i. 3&1. — Section noroiM Ihi' uftro-imcrAl UicsTiirtit after tyinK it off (Proiut). 

tite liaae of tfie Parametrium. — One commences the freeing of d 
vagina on its posterior face, proceeding in the avascular sep 
rable zone which results from the coalescence of two fine lay* 
of the embryonic [Kriloneal cul-de-snc and which leads alurt] 
as far as the recto-uterine cu!-de-snc of the adult. The isolat' 
of the vagina only pre^cntM difficulties at ils lateral Imnle 
where one finds the following vessels: tlie long vaginal brand 
coming from the curve of tlie uterine arterj*. vaginal artcrrt 




OPERATION 



278 



branches of the hypogastric artery and ramifications of the middle 
hcniiirrhoidal and collateml vesieo- vaginal veins. Acconi- 
[Kinied by fibrous tissue strinids. these various vascular rami- 
fications constitute the [irin<-i|)iil means of fixation of the vagina, 
the levators only contracting with lliis cnnal during simple contact. 
Wc niiist cut acmss these and tic llicm together, taking care to do 
so beloH- the uretera] zone and not to open the vagina (Fig- 24ft). 



Pio. 253. — Continuous iutur« of thv ptriUiDeiil eiil'd^'^tao (Fruust). 

This freeing of llie lateral bonJcrs of the vagina ]>ennits of it 
being drawn down and fucililates tlie access to the parametrium, 
the methodical extirpation of which constitutes one of the 
principal stages of the oiieration. Under visual control, dissect 
llic ureter in its latercM-ervical course; then tie the uterine artery 
or wait until the end of the operation. 

Opfiiing of the i'crifoneum, Hemnval of Utents and Vagina. — 




280 



HVSTERKtTOMY HV THE PARAVAUINAL ROUTE 



Once the ureters are well lilH-rated prcKred to the opening re- 
sijcctively of llie aiitcrioi- uml posterior ])oritoneal cul-de-sacs. ^J 
Tliis opening is made with scissors, the fundus of the uterus is^| 
ailed down and forwanl. Cut llirough and successively tie the 
round ligament and then the utero-ovarian ligament of the same 
side external to the adnexa (Fig. 250). The hroad ligament is 
cut through in ils turn and the uterine artery is tied, if it has 




■T 






Fta. 203.— Aapoot «( paru at tlic ooncliMioii of the oporntion (Proiut). 

not already been done. Conclude with ligature and section of 
the utero-sacral ligament (Fig. ^51). 

Tlie same manipulation is repeated on the opposite side. 
Thus we excise the adnexa en bfoc with the uterus and vagina 
closed and containing iJie cancer. 

Closing of the I'eriiuneunx. lieconntruction of Ute Vulvar^ 
Ring. — The |>eritoncuni is elfisr<l again (Fig. 252). The two 
anterior placeij sutures unite the lateral borders of the remaining 




RESULTS AND INDICATIONS 



281 



vaginal cuff in such a way «s to create a support to the Madder, 
then tlie vulvo- vaginal incision is closed up by means of deep 
sutures, taking up "en masse" all the tissues. By the vulvar 
orifice thus reconstituted tlie gauze drains protrmle from the 
ojieralive cavity (Fig. 253). 

Results and Indications.- The results may lie viewed from the 
stan(l|><>int of immediate and more remote ri'suJts. 

Immediate liesulti. — SchucliaMt in 87 cases had 8 deaths, or 
9.6 |)or cent. Twice he has had injury to the bladder, twice 
injury to the ureter, and twiee injury to the rectum. Schauta' 
ill 336 cases had 30 deaths from the operation, giving about 
10.7 per cent. In reality, tlie mnriaiity is actually much less 
frequent In 1907- 1908. it was 5 in 88 or 17.8 per cent; in 
1908-1909. it was not more than i in 50, or 4 per cent 

The operative complications have been diminishing. 

In 1901-190^, 4 injuries to the ureter in 47 operations =8.7 
per cent. 

In 1902-1903. 2 lesions to the ureter in 29 operations =6.7 
per cent 

In 1904-19O5-1906, only 1 lesion to the ureter in 49 operations 
=2 per cent 

In 1907-1908-1909, lesion in 336 operations, the rectum 
4 times. 

Htmotr ReauUs. — In 42 cases which he followed Scliuchardt 

found 15 patients cured two years after operation, which is 

about 35.7 |>er cent.; Schauta found 36 patients well after five 

;^ears, 19 after four years. 21 after three years, and 20 after two 

years. 

' SdiMIt*. The ICxtcn<l<'<l KpRitllH nr ICxtirpntion o( the Ciincof of Iho Cervix of tbo 
Uunu by tlie l^nlari^<(l %'ai;>""I Huuto. AnnnUt J* ffyrtieologU, Pftria, 1909, p. 943. 



1 




CHAPTER X. 

PERINEAL AND SACRAL ROUTES. 

Summary. — Transverse and sagittal perineotomy. — Operations by 
the sacral route, parasacral incision, resection of the rectum. 

The ]>erineal and sacral routes have been employed on rare occasions by 
a (vrtain number of gynecologists. 

1. PerineotcHiiy. 

I't-riin'otoiiiy has been practised by a transverse incision or an antero- 
posterior incision. 

Transverse Perineotomy. — In transverse perineotomy, advised and 
ilcscrihed by Otto Zuckerkandl, a flap in the form of / \, the figure is 
IriK'cd on tlio iMTincum. The transverse portion of the incision measures 
7 I'lii. and lies abi>tit S cm. in front of the anal orifice; the two divei^nt sides 
ar*'- din'<'tcd toward the ischia; in deepening this incision one arrived to 
peiielnite the recto-vaginal space almost to the recto-uterine cul-de-sac. 

Olirritliiin. ~.\fter incising the skin and superficial fascia, separate up the 
Hup, nnil cut llm>ugh the fibers of the external sphincter which go toward the 
foiiri-Ui'lti' iind then .separate the rectum from the vagina up the whole length 
iif the sphincter. Then cut across the fibers of the recto-vaginal muscle, 
siHuc libers of the levator, and one finds oneself in the easily separable space 
iiilcrniediute betw<H-n the vagina and rectum, from whence one may easily 
luiikc way as far as the ))eritoneal cul-de-sac. It is sufficient to press the 
rectum buckwanl in order to have a fully exposed, widely opened wound, 
whose base r('u<'i>es to the peritoneal cul-de-sae. This wound is limited 
behind hy the n'<'tum, in front by the posterior face of the vagina and later- 
ally by the ischia, which are covered by the fatty tissue of the ischiorectal 
fiwia. 

t'liti peritoiteuni lieing opened transversely, introduce the hand, tilt into 
live wound, the uterus and adnexa, ligature and cut across the broad liga- 
uivuts, open through the vcsico-uterine peritoneum anteriorly, separate off 
the bladder and excise the uterus. 

This ki|ieruti(tn has been used in opening certain pelvic abscesses in order 
U> tviitvivc vaginal nciiplasnis and to excise advanced uterine cancers. 

282 



SACRAL HOLTE 



283 



Sagttt&t Perineotomy. — In sagittal pcrin^olomj-, more often cnlicd 
vorticul perineotomy, the ini-isJon is usuully iititer(»|)0!iterior. Siinger,' who 
ha» had iuo.it frequent recoume to it, makes an incision to the side of tlic 
median line— commencing nt the level of the jKwtcriur lliird of the laliium 
major und terminating 2 cm. external to tlic anal orifice between tbia orifice 
and the ischial tuberosity. lie cutK ucrosH the IcivittorM. 

2. Sacral Route- 

The ineiuon may be nimply parallel to the sacrum when it is callcil the 
paramcral route; it may accompany u more or Ic!" exleuMve resection of the 
sacrum; it is then properly MpenkinK the sacral route.^ 





FlO- 254. — TnioNi-em.' iierineolomy. I'lo, 2M. — Sftgiltttl puiiicutumy. 

PRrasacral Route.— This may he various. 

E. Zuekerkandl luaken an incision |iuriillel to the border of the .lacrum, 
extending from the poslero-inferior iliac spine to the ischiorectal fossa at 
equal di.tlance from the tiiberii.oity nnd the rectum; he cut.'< thritit^h the mus- 
cles and the ligaments without fear of injuring the vessels and nerves of the 
vdntic foramen, which tiecxlernally. 

Wblffer makes an incision which commences about I or 8 cm. exicmul 
to tiie incLiioii of the coccyx and .HAcnini: Ihi.t incision, like an nrc of a circle, 
passes near the rectum and terminates in tlic perineum about 2 or 3 em. from 
tli« inferior c<immt!t.>inn> of the vulva. He Incite:* the gluteus maximus, tfac 

•8Ani5«T. Arehir f. Cyn.. Hcrlin, 1890. T. XX.Wll, p. lOfl. 
■Torn«r And lUrirnunn. AnntU** 4f. gyn.,Wnt, 1S9I, T. U, p. St. 




284 



PURINCAL AKD SACRAL ROUTES 



sei&ttc ligaRK^nU. large and small, near tlidr Insertion, and then Uw levator 
uiii. iiflcr which he M-imrnli-H Uie n^ctum from tlif vnjfiiin. 

Sacral Routt. -In the sacral route the osseous resection mar be more 
or le*« extensive; KnuHkcrcsecl-s tlieroceyv and thelefl portion of thesjicnini, 
folloving a line the boriKontal part of which pa^se.'* below the tliird sacral 





I'lo. 256.— Ktnikc 



Fio. 3&T. — Ro»x. 



foramen; Roux uiakcH a transverse incision below the third saend runiiiien: 
Hiieheneg}{ niakc!< a r*'.iection intermediate in some respects to the olhcr two, 
taking cure to include the nerves proceeding from the right fourth sacral fora- 
men and the right Nacro-sciatic ligaments. 

Others have done temporary resections, cutting tmnsversely acKk** the 




Fio. ZfiS.— Hocbcoegg. 

sacrum below the third saeralforamen.aflerfollowinf; its right border (Roux). 
or making an oblique Hection whieh pa».%f.t to the right iM-lueen the third and 
fuurtli sacral foramen, to the left, through the lateral portion of the eomu 
(llegar and WJedow). 




SACRAL ROUTE 285 

The important point is to get good exposure of the parts; the opening 
of the sacral canal is of no importance because the dura mater is not diseased, 
and it eventually forms a fibrous and resistant cicatrix. 

These operations by the sacral route have to-daybeen almost abandoned; 
they present certain difficulties and are exposed to complications. Some- 
times there is trouble to recognize and open the peritoneum; theiatestine, 
bladder and ureter have all been injured. An interesting point to note is 
that the injured ureter is always on the operated side, which is explained 
by the fact that it separates easily from its cellular connections with the 
pelvic wall and that, being very mobile, it is easily drawn upon and injured. 



PART III. 
OPERATIONS BY THE ABDOMINAL ROUTE. 

CHAPTER I. 

SHORTENING OF THE ROUND LIGAHEHT5 IN THE INGUINAL 

REGION. 

Summary. — Anatomical Sur\-ey. — Operative Technic. — Results and In- 
(lic-ntious. 

Tlii.^ :j)iortening in the inguinal region of the round ligaments 
was lulvoeated by Alquie in 1840, but his work had fallen into 
oblivion when Alexander in 1881 did it and Adams in 1882 
hel|H'd to familiarize it. 

( -oninionly described as Alexander's operation, the shortening 
of the round ligaments is sometimes known under the name of 
the .VIi]uit'- Alexander- Adams operation. 

Anatomical Recapitulation. — The round ligament, commenc- 
ing lit llu' cornu of the uterus, lifts up the anterior fold of the 
bi'oad liganu'ut and runs down the inguinal canal, where the 
I'ord Invaks up into a series of fibers which separate to become 
iiiscrUHl into the connective tissue and skin of the mons veneris, 
the pillars of the inguinal canal, to the periosteum and spine of 
the pubis. 

In its inguinal course, the round ligament is a veritable cord 
wUii li i^ souictiiucs accompanied by a diverticulum of the peri- 
loiiruiii \iahal of Nuck) situated internal to it. 

TKc lountl ligauient. the peritoneal diverticulum when it 
(Aiiti, and numerous veins are united hy cellular tissue into a 
void, whivli crossfs posteriorly, superiorly and external to the 
(iiiii-nilrir vcssfls. Above it lies the inferior aMomino-genital 

Vl the \v\v\ of the external inguinal ring the terminal fibrils 
wl \\\v (okuul ligauu-ul an> in a great measure included in the 

■2m 



OPERATIVE TECUNIC 287 

pad of fat, Imlach'fi |>a<l, which enters the canal n.s a fatty 
ctird- 

Operative Technic— The round Hgainenl rHiiiifies at the level 
»f the pad of fat, which covers the external inguinal ring and 
we must therefore search for it in the inguinal carnil, where it is 
stilt a round cord. 

The first stage of the operation consists in exftoaing itte 
inguinal rnnat. To do that make an incision of 7 to 8 cm. 




Fto. 350.— External oriiioe of the Inguinal oaiial. 

long, commencing at the spine of the puhis. parallel lo the 
crural arch, an incision which generally is concfulfd hy the 
pubic hair. 

In order lo be sure of not mistaking the fascia transversalis for 
till" H]M>ncurosis of Ihe rxtmud obli<|ue. wliicli nmy be the case 
with fat women, it is advisable to deepen the incision externally to 
a point where one is certain to meet with the solid and resistant 
plane of tfie |K>arIy external oblique. Where this is fully ex- 
posed run a grooved director along it from al>ove downwardjund 






no. Saa— EiI«*m1 K^ «t lacaiMl cwmL 



alwavs appears on looking deeper as a bluish colored cord, 
re<idfne<i in pari by the \-eiwclH. Wien recojinizcd it la i^ated. 
»nd with the director we tear throtif^h the fibrous tracU which 
iHiitv it to the walU of the canal. Press Iwrk with gau/^ the 
tH'ritoncuin which envelfips it. By gentle and [continuous tnic- 
lion it limy l»e grndtially brought out. unli] it may Ik* fn^ed for 
almut 10 or H cm. Now Ihc !«c|Kiration of the |>entoneum lie- 
iMUtC!! more difficult, an the uterine cornu rests against the deep 



OPERATIVE TIX'HNIC 



269 



face of the wall and opposes resistance lo llie Iraclion. It 
liap[K'ns ofttMi during llicse nianipiilatioiis tliat the abdomen is 
opened, not that this is of such im]>ortjince, hut it is even of ad- 
vantage lo s;»-sleinatic»Ily o[H-n the peritoneum in such a way as 
lo be able to ex])lorc with tlic finger the corresponding adncxa 
and to lilicrate, if nwcssarv, iiiiy jidhesions that exist. The ira- 
porlant jjoint is always to act with gentleness in such a manner 
as lo avoid rujiluring the ligament. 



Fio. 2AI. — The roumj limmont i- h.',-A irurn ilir ini ii.hi-iiin, the cii1>d«'9wi) of which 

Dlfiy he si'vii iiiiTiiodiutcly ttrluu tilt' rflrautor. 

The canal is closc<l uit in Bu-ssini's u))eratii)n. suturing the 
peritoneum, uniting the internal oblirpie and the transversalis to 
I'oupart's ligament, taking vhw to include the round ligament in 
tlie two or three inferior sutures (Fig. 264), Conclude the 
fixation l>y uniting the ligament to the superficial portion of the 
a|H>neurosis. The leruiinal port of llic round ligament is then 
resected. 





290 



SHORTENING OF THP, ROUND I.IGAMF.NTS 



T)ie aponeurosis of the external oblique and then the shin 
are suturetl without drainage. 

'l*he same niaiiipulations are carried out on the op]>o»ile side; 
the oi)eration is concluded by the application of a vajjinal lam[K)n 
or hy that of a pes-sar}-, which is destined to prevent the uterus 
from exercisinjij the traction of its weight on the lixution sutures 
of the ligament for the first few days. 

ViirmuK Hiudilication^ have brvn udd^I In tlic ty[>c of oj>cratii>n wv liavc 
justdi-wnliL-cl. Inplaceof Disking two syninii^lrirntincuions some nprralors 




make a aingle curvml im'ision to it. the ronvrxily oo a lovcl with the ptihis 
(Buiiiin.' Fhiinclileii') iiixl othen) doiw tlir- I'linnl l>y tiinkm^; um' of llir round 
ligament thmiif;h which the suluivs |)ii!i<i in a i^piritl form in IrawFAinfi from 
on« wall to the othi-r tAliW). !ii K]ililliii>; il an<l thrnitlin^' rnoh uf il^ hiilrcs 
Ihroiifih onv of Ihv lips t>f the incised caniil iind tlivn tying tlipni logplher 

' Rumm. in N*. SlMHlicr. Arch./ir Oyn., Borlin. ism, T. I.VIII. p. 492. 
•Vlaitebtu.Monauehr./.Gtb.uitdG^., B«rti». 1S9U. T. IX, (i- 36. and T. XI, p. 
* Robert AMu-. Flxntion of lite Rouad LipmuDt in iUcxsoJi^r'a C>|wratioD. At 
^Smt: Plitlad., Ueoember. ItlBA. p. 699. 





OPKRATIVK TKCHMIC 



291 



I 



(Juvara*)- Others bend the round ligament upward and outward and fi\it to 
Uic rxlernul fat-e of Ih*- aponeurosiis of Ihp pxt«-rn»I oljlii|ii(r in the di«'c'lioii of 
the anterior BUpcrior spine (Kocher'). while others unite the extremities of 
the rcscclit] round liptinciit.^ toKi-lhcr (nok-ris'j. Boureart. iiftrr dniwiiig 
rtronnly on the round ligament, ineiscs the peritoneum immediately external 
to it: Hip trndion on the round lignment)! dntw« the uterus forwHnl: thoMr on 
the cone of peritoneum act on the adnexa. In thLs way we can graduate the 
action on the utrniM and ovari' ns we wi.th. fixing tlir round ligament to the 
a)M>neurosi!i and then closing the peritoneum in suturing llie external cone 
to the round ligament more or lefts distant from the uterus as there is ncccx- 
sily for drawing the adnexa forward.' 

Results and Indications.— 77«r imtucditite resuttn are gowl. 
There is no trouble in connection with the hlndder. The remote 
results sluuild Iks vitMveti from a tri]>lf slandpoinl, viz., orlho- 
pwHc. theraiM'utic and obstetric. From the urlIio|H'dic point of 
view, if one ha.s l>een can-ful to .secure a forced nntedeviation the 
connm arc in contact with the abdominal wuIIm and the retiults 
are generally good: it i-s nire to Hnd recurrences in cases of 
retro-uterine adhesionii or when the operution has been used 
for pn>ln[ise. 

From the IlicrujM-uUc aspect, pains only occur when coin- 
cident with the deviation that are inBammatory lesions, in par- 
ticular those of the adnexa. It has been deiiioiislrate<l that a 
consecutive hernia is rare if the walls have been well sutured. 

From succeeding pregnancies, inguinal shortening of the 
ligaments seems lu exert no bad influence. 

The examination of imniediale and remote effects leads us to 
llic conclusion that the operatimi is indicatetl in siin]>Ie retro- 
deviations and prolapse: if in the latter case, it is combined with 
a plastic vagino-perineal rej)air. It ought only to be done, 
however, during active sexual life when the ligaments are well, 
developed ami capable of siipi>orting the weight of the uterus. 

In practice we do not perform this operation much: 

1. Iiecau.se, while it gives good results, it is necessan* that 
Uierc be no retro-ulerine adhesions nor inflanniuttorv lesions of 



• Juvmra. Prtiitr midirtdn. Pari*. 1901. p. 178. 

* Kocher, Chir. OpertiUoiKlphre oc in l.ni)(, Arth./ir Gun., BerlJD, 18IKf, T. XLIV, 
p. 84». 

' UoUrif, .Vaui'cUe* Arehiii d'obMtriqut ti de iiyn., F»l>niftt7, tS8U, p. 49. 
' Bowearl, Ann. d» f/yn., Parts, lOOT, p. 705. 





292 SHORTENING OF THE ROUND LIGAMENTS 

the uterus or adnexa; that in all such cases, retrodeviations 
which present no painful symptom may most often be left to 
themselves. 

2. Because we possess to-day, as will be seen later, most 
excellent means of fixing the uterus in good position. 



CHAPTER II. 

ABDOMINAL CELIOTOMY. 

Summary.— Ococra I tpchnic. — Operative prt'catitiooa (operator, sur- 
rauniJingx, ojieraleii). — MeiJinn ccliotoinr (iiirUiun. limitation of operalivp 
field, treatment of adhesions. hemustasiR. peritonization, examination of tht^ 
Jtpprndix, elosin^ of llie wall, drainiige). — Transvi-rte cfliuUnnv. — I'ost- 
operatjre precautions.— Com pliealions (shoek. hemorrhage, peritonitis. 
inl<v«liniil orclusion. pDlnionarv eompIiratioiiK, parietal <iMpptiratic>n, fiKlula. 
phlcbitiii eventration). 

Under the name of coliotomy is meant the opening of the 
peritoneal ca\'ity or celom. The means of access to the cavity 
are multiple. We have already described it.s opening under the 
name of vaginal celiotomy or, more correctly, colpo-celiotomy. 
Most often the entrancr into llie abdomen is through the abdomi- 
nal walls; it is abdominal vcliutomy. 

ThLs term, abdominal celiotomy, tends to replace the ineorreet 
form laparotomy which means, literally, lateral incision. The 
word laparotomy should Ije rejected as also that of gastrotomy 
which was generally employed at one time and is now reserved 
to the opening of the stomach. 

1 . General Technic of Abdominal Celiotomy. 

It wa« once rt^ganle<i as a very .seriou.s operation. 'Hie 
patients died of hemorrhage or suppuration and the rare cures 
were considered as happy chances. Actually, the opening of 
the [)eritoneal cavity, executed aecording to nde!! and by a 
surgeon knowing bis work, presents no longer any danger. 
This is due to the introduction into surgical technic of antisepsis 
and asepsis. 

It is important to draw altenlion to the employ of purely 
aseptic methods in aWominal surgery. From tht time that the 
peritoneum m ofKned, leave all antiseptics on one side and only 
employ asepsis. 



3d4 



ABDOMINAL rEUOTOMY 



The action of antiseptics on pathogenic organisms is largely 
counterbalanceil liy injurious fffects to pcritniieal omiotheliuia. 
This deslruclion of ]>eritoneal endothelium, as llie laboralori' 
exjicrinirnts of our collragui- l)ell>el prvA'i'd, coiiliriii our clinical 
results and leave no doubt of the disastrous consequences that 
may he occasioned. 

Certainly absolute asepsis is never reali/e<] whatever prtH-au- 
tions are taken. It is not indisjM-iisahle; one should endeavor 
to obtain it as completely as possible, but happily one finds in 
the body elements ca|KibIe of resisling a microbic invasion of 
the ojK'rative field. The jjeriloneuin possesses a considerable 
resistance as our clinical observation has established. It is not 
rare to observe ]>atients get U-ttcr withiHit Ilie least [loritoneal 
reaction although they present a i)arietal su|jpuralion some days 
or weeks after the operation. Hul. in order that the struggle 
may be efficacious, il is necessary that the tissues preserve all 
the phagocytic action which a strong antiseptic may impair. 

The employ of anti.septics has other drawbacks which, 
although not immediate, are none the less important. We 
refer to extensive a<llicsions, produced by the irritatitin of the 
serous membrane. The ]jroduction of these adhesions has so 
many drawlmcks that il is sulficient alone to withhold their use 
in abdominal surgery. 

In another sense, the more remit Irrtttitra! improtmnenU have 
contributed to n-dutx- Ihe risks of celiotomy. 

These chief improvements are three in numlier: limitation of 
the o]>erHtivtf Helil, the suppression of lat^> {>edieles and the 
doing away with intraperitoneal surfaces. 

. The Jiniilation of l\n- tt|H'rative liel<l, as far as one is able. 
results in the reduction in .si/e of n possible infected zone and 
renders the operation extraperitoneal as it possibly can be. 
Till- following result is thus obtained: 

1. IJy the use of the inclined plane. 

2. By the metlK)dicjii i.sohitioii of the pelvic cavity wiUi 
sterilized compresses. 

Wiile Scultet used the elevated pelvis |>osition. with an 
inclined plane, it is to Trendclentmrg that Ihe merit is due of 
using the incline<l plane in order to favor descent of llie intestine 
in all 0|)4-rations on the {K'lvic cavity. 




GENERAL TECHtnC OP ABDOMINAL CELIOTOMY 



395 



Since 1800 I have, in Paris, eonslaiiUy usp<I the incline<) 
plane, and at the same time my friend Delageniere used it at 
^^l^ns: at present its employ is ^■iicral. 

^^V In this elevated [lelvis position, ^vith the body at an anfjile of 
m 4.5 degrees, the intestines fall toward the diaphragm and leave 
the operative field free. This inteirenlion renders the operation 
easier and safer. It has heen said that it inav lend to piilmonarv 
or cephalic congestion. In some stout women, with fatigued 
hearLs, there is at first some facial cj'anosis. hut it is very excep- 
tional to find that this extends to a degive involving the return 
to the horizontal position. 

The cmpliiif nf tixffitir rUilhs which our master Ferrier made 
common is the natural complement of the inclined plane. By 
placing them meth<idically, one may completely isolate the 
pelvic from the rest of the ahdominal cavity and thus the risk of 
infecting the general peritoneal cavity is reduced to a minimum. 
For this j)urpose a good nne-ithema with calm and regular re.'^pira- 
tion permits of the constant and regular maintenance of the 
coniprt>sses helow the intestines and constitutes a considerable 
operative adjuvant. Personally, 1 consider that a good anes- 
tliciiitt is nion.* inijiorlant tlum a good assistant. 

Tkt suppression of large pedicles constitutes an improvement 

none the less important. The ligature en manse of (»ediclcs. 

formerly the cust4im. ]>resents numerous drawbacks. It is 

_ complicated, dangerous and generally useless. To show how 

P eoDipIicated it is. one has only to think of the numerous ligatures 

devised to accomplish it (chain ligature, Tait's knot. lhiiit<M'k's 

knot. etc.). It-s danger is emphasized Iiv the way it slijis when 

most cai-efully applieil: most dangerous hemorrhages of course 

result from this wlit-ii the ab<lomcn is clos^'d; useless also iMMrausc 

I these large ikkHcIcs are often avascular niong the greater course 

of their length. Thus when one pr<K'cc«Is to the removal of the 

Iadiiexa. two small ligatures, one placed externally on the utero- 
ovarian artery and the other internally on the uterine artery 
suffice to M-curc the hemoslasis. In these conditions why is it 
necessan* to tie an enormous ligature aroimd the upixr part of 
the broad ligament.^ That is not all. In addition to these 
immediate drawbacks the large pe<licles have even more remote 
results. They present a large raw surface ready to contract 





296 



ABDOMINAL 



adhesions. Everj- sur^-oii has seen those sad cases where a 
bilateral excision of the adnexa lefl hvo large more or less in- 
fecled |)t'<licles, as painful as tlie organs removed. 

The supirression of the rawed intraperitoneal surface con- 
stitutes another improvement. The reconstitution of the |>prit- 
oneum over the raw surface and ligatures, commonly known 
in France a.s "|)critonization." has the advantage of preventing 
these raw surfaces from exuding their products into the [Krit- 
oneal cavity. It is also sufficient to prevent the secondary 
formation of adhesions, a source of pain and such grave com- 
plications as intestinal occlusion. 



«. Preparatory Measures. 

We will consider thus under three Heads: the ojierator, the 
patient, am] the surroundings.' 

Operator. — The surgeon who undertakes a celiotomy should 
)>e quite well; a goo<l physical state assures the oj>crator ttiat 
moral condition which enables him to form and execute decisions 
rapidly and well. Ife, his assistants, and liiii material should 
be aseptic. 

\Yc will not go into the means of securing this slate of affairs. 
Rubber gloves should always Ijc employed. They should Ik- 
usetl in alt abdominal operations. Masks, however, if the 
ojicrator iloes not s]>eak, ap]H->ar to us to lie useless. Personally 
we only use (hem when we have coryza or sore throat. 

Surroundings. ^The surrtHindings ai-c not of such great 
importance as one would be led to believe a priori. It is. how- 
ever, prudent to avoid operating septic cases in the .same theater 
as one dtws celiotomies. It is advisable to give any spectators 
aseptic blouses, to caution them not to touch anything, not to 
crane over the ojK'j-ative held and not tu brcalhi" on the wound. 

Patient. - It is the patient who is above all the object of the 
pre[Kiratoiy- attentions. It is essential, when there is no absolute 
urgency, to prepare her at the operation. 

1. To increase her resi.stancv a.s nnieli as possible to Infection 
and to stimulate the function of her in such a manner as to 

* 8m tho diwouMiian, Fn'noh CoDflrgn of Svinty. 1009. nnd HoljrbiLeli, BiniKC Bemerk . 
Obor Vor itad Xiuihbch&iMl. gyDOcOp., Samtu. Jfti'n. Vortr., 1010, 



PBEPARATORV MEASL'BES 



297 



I 

I 

I 



I 
I 



obtain an easy eltmiiiatiou of toxii- suhstances iti cnsi^s where an 
infection may be brought about. 

2. To rentier lier skin a.sc|)tic. 

1. Preparation of the Palient. — In order to place her in the 
best possible condiltoiLs of reNistance, we should iihsisl l>efore 
the oiKTotlon a moral and physical repose of some days, giving 
hypnotics if ne<*cssjirj- to the neurotic subjci'ts. We think it 
is as well uot to stale Ijeroi-elinnd the day of the o|>eratioii in 
order to avoid apprehension, sleepless nights, and the state of 
terror which sometimes gives rise to complications at the com- 
mencement of anesthesia. If the patient is a little iigttaled, we 
give a s«-dative l«!fore tlie day of operation in order to secure a 
good calm night. 

The r^imc is notliing s{H>cial. Avoid objects difficult of 
digestion. In patients with glycosuria, albuminuria and some- 
times stout subjects, a .s]K-<'iul regime is ti> Ite recommended. 

In a general manner of speaking avoid all operation in 
dialietic subjts't-s. above all in llio.sc with polyuria and Hal>byskin: 
on tlie conlrar}'. the simple pivsence of a uiodernte <|uantity of 
sugar, combined with a good general stale, does not coiitraindi- 
cate an operation. However, it is advisable tiefore operating to 
give a r^imc of milk and alkalies to reduce the sugar.' 

Albuminuria, which many gj-necologist-s think is a contra- 
indication to any o|H'nition. certainly is an unfavorable synif)- 
t<im. It is none Ihc less true that in <Trlain eoiultlions, such as 
uterine fibroids where it results from the interference of the 
sexual function by tlie ]K-lvic tumor, the operation is absi>lulely 
indicated. In such cases we operate after giving them a course 
of fifteen days on milk. We are doubtful of cases where in addi- 
tion to albuminuria there are also epithelial cylinders in the urine. 

In stout subjects the celiotomies are more difficult, longer, 
and more dangerous. It is a «piesliou when Iherc is nothing 
urgent whether a course should not be suggested enabling 
the patient to become thinner. Pam-Iiet advi.scs a regime in 
which the essentials are vegetable soups, green vegetables, fruits, 
<)niiiges. with water as lu'verage. Others recommend a milk 
diet, consisting of i l/i liters per diem. 

' Sofiii- nutlion have l>lain('<l trliloKifurm lu tbi> cautc of dialwlic eomtt; In ivality 
tbr (]tiMtiua id sncniliciiti in iwcuniliiry. Coma has come on mttvt linipLe •pinal ancit- 
tbxoA (t'Olh. Ilulituidi). 





S98 



ABDOMtNAt. CELIOTOMY 



I 



When the patients are run down and enfeebled, amonfr ll 
who have worked up to the last minute and arrive at the )ia<ipital 
quite exhausted, it is advisable to recommend some dovs of rest, to 
give baths, a fortifying diet, tonics to stimulate llie exeretioas, and 
even if the heart is feeble to give a little digilali-s or strk'ehninc. 

We attach a great imftorldnre to .the careful denning of the M 
mouth. We may thus iliniinisli the occurrence uf pulmonary " 
complications of postoperative parotitis, etc. llemove the 
tartar and then iiriisli the lecth well, etc. 

The evacuation of the intestine by purgatives, besides being 
tlic best of disinfectants, has the advantage of cleaning the 
digestive tube of its contents, liquid or gaseous, which reduces 
the volume of the intestine and facilitates the intraabdominal 
manipulntioiis. It is atlvisable not to give too much purgation 
and to avoiii drastic purgatives. We give an oily or .saline laxa- 
tive two days befori' the operation and an enema or laxative 
the day Iwfore the operation if the primary resi)lt lias been 
unsatisfactory. We may thuK l)e certain of avoiding the dis- 
advantages conse<|uent upon the continuation of purgation on 
the morning of the oiK-ralion. Never give violent purgatives 
as the fatigue of the muscular intestinal wall helps to augment 
the post opera tiv(> bowel pai'Csis at limes when it is neci>ssary 
to induce contractions of the bowel for the discharge of pus. 

2. Diainjcrtion oj the Ofterative /itv/wn.— The day Iwfore the 
oi>eratioii the skin is shaved. The patient is then cleanei) up 
with soap and water in such a manner as to .stimulate the skin 
FunctioiLs. Be particular to remove epidermic debris. 

The vagina is disinfected with repeate*! antiseptic irrigations 
and even most carefully lialheil with soa|j and water on the 
morning of the operation and then {>acked with iodoform 
gauze. 

Latterly surgeons have endeavored by ante-operative meas- 
ures to combat the heinorrbugcs, intravenous conguhitioiLs, and 
infections, secondary to intervention. 

They set to work by ascertaining the coagulability of tlie 
blood, and if it is not normal, endeavoring to obtain that state 
by the adniinistnition of calcium .salts, subcutanenus injections 
of gelatine o to 104). animal serum an<l milk diet, or anti-coagu- 
lants (citric aci<l, potas.sium citrate, vegetarian <liet. Prussian 



/ 




tw 



ag» 



blue injected intravenously) and to thus prevent the occurrence of 
hemorrhages or that of thrtJUihosis or embolus (Wright). 

Others propose to immunize the patient against sut^tcal 
infection by a streptococcal, staphylococcal or coljlwteillary vacci- 
nattou. Unhappily, there is yet no senim which prevents the 
development of infection in man. It has been suggested to 
increase the resistance to infection by making a pre-o))erjitive 
leucocvlosis. Tlie subcutaneous injection of 20 e.c. of a solution 
of 1 ]>er cent, nucleinale of soda has been recently declared as 
valueless (Aschner and ^''on Graff). 

Perionallv \vc have never used any of these plans, and their 
efficaciousness apjjears to us to be incompletely established. 
On the contrary, when llic patient is feeble, we do not hesitate to 
give her, the day before and the morning of the operation, a 
subcutaneous injection of 3 to .500 c.c. of physiological serum. 

fjrgency Opvration.—ln case of urgency it is evident that 
preparatory treatment should lie reduced to a minimum. Be 
content to stimulate the patient with sulicutaneous injection.s 
of normal .valine or in extreme aiuctnia with intravenous ones. 
Al.<ui, give injections of strychnine and disinfect the skin with 
two applications of tincture of iodine at some minutes interval 
^nxssich). 



Ci 



3. Operation. 



The ojwniug of the abdomen is generally carricil out in the 
median line; some operators prefer the median vertical incision 
to the transverse suprn]>ubic one and differentiate them by the 
names of median and transverse celiotomies. 

A. Median Celiotomy. 

Preliminaries of the Operation.— The surgeon and his assist- 
ants after having disinf(H.-ted their hands in the usual way and 
put on rubber gloves, and then placed in largt- rewptacles the 
necessary armament for the operation: large cloth dressings, 
sterilized gauze with which to sponge, simple or ehromicized 
catgut, .silkworm-gut sutures, Uie usual abdominal instruments 
and very few special ones, nire metal retractors, a large valval 




300 

rrUactor the fised pataA at vUcb fies b et wg< » Ae leys, a bluDt 

small ^luiteox's fam|M. The Beedka la be ased far tbe sutnTct _ 
are ihafpeaed before and kept brt »ee a ■*tF?*" 'l cmnpreaaea. f 

During these pcepamtiom. the patimt ts aoestbeiUxed in htr 
bed or in an •djoian^ rooot. The bbidder is emptied. Wr 
UM> chloroform modlr b er aigt the respiratioo is calmer than 
that induced by elhcr and in not prodacing aitj- cephalic coo- 
flection proro it* suprriori^ in this respect for operatioiis in the 
indinerl [ilaae. as is >o tronstaatlj done to-dar. 



fU. 3ll3.-'lArgenlviilM'rrtt«rt««'«ith[uftu<lpmatpUoeiI betwrcB tbe It^ (I>oyMi% 

Wicn the anoslhesia w sufficifntly complete to enalilc the 
pulieiit lo 1m- traiis|>orted, she i:« brought into the operatiuii 
Iheatpf and placed on the table which is provided with shoulder 
piece* so that when her legs are fixed in the elevated position and 
luble head lowered, she will not be sus[)ended by the knees. 
The arms lie alongside tlic b<Kly and are lie<I with a serviette or 
bandage. Never place them as one often sees in forced abduction 
u this exposes them ti> (KiralysiH of the roots of the brachial 
plexus, which. altlmu^Ii sptMitaiieously ca[>ablc of cure, neverlhe- 
lefti* cau^CH the patient much worr)'. 

A warm application Is applied over the chest, a !»econd is in- 
ftinitated under the kidney's. 

A frciHh abdominal toilet is made bv an assistant. Brush 



i 




OPERATION 



301 



t 



I 



I 



well witli soup and water.' ether, alcohol and 1 to 1000 sublim- 
ate. Be careful to disinferl the umbilicus which should Ijc 
drawn out wilh a [>air of Koclier's forceps. 

When the skin liisinfcction is finished circumscribe the 
operative area with sterilized cloth cornpresscji. slij^lillv moist, 
and thus limit our operative field. The inclined plane is now 
put at 4o degrees, the minimum to get a satisfuctorv r(*sult.^ 
The operation then commences. 

'J'he surgeon is on the puliciit's right, and behind him is a 
table on which are the flat trays containing instruments, u box 
of gauze compresses, two boxes of cloth cnmpres.scs (small and 
large), and facing him is the principal assistant with his table 
on which are gauze compresses, sutures and ligatures. To 
llie surgeon's right is the second assistant, who will hold during 
the operation a valvular or ordinar)' retractor. He may not 
be required if antonuitie retractors are used. 

During the whole course of the o[)eralion, the surgeon and 
his assistants slumld avoid cniuing their ImiiiLs over the wound 
and they should not s]>eak or breathe into the abdomen, as their 
breath is infective. 

Abdominal Incision.— The ost generally employed incision 
is the mc<han vertical subund)i]ical. It should !»■ long enough 
lo permit <loiitg the intraabdominal mnnipulntions with ease and 
yet not too long .so that loops of intestine keep appearing in the 
wound. It varies from 4 to 13 em. and more; an incision to 
permit of the extraction of large fibroids may attain great 
dimensions. 

Generally one commences wilh a small incision a little Wlow 
the mid point of a Hue between the umbilicus and pubis.^ Cut 
through the skin, the subcutaneous cellular tissue and the 
aponeurosis in a line with tlie white line. In fact, tlie incision 

' In order to get the best mtilliwith lh« bruxh wr uw a tnmiHiiiof wood ■hAvinipc 
■• Utl« tampon i« of imi valup. it ia WMyl uiice*nd thrown ikwny. Wo iiac Uqiiid BOftpuid 
A lilll« mter (wliite Mmp 1, bluok noap 1. uit 1. water 3, iiaphlol, U,<]3£. MseiieeoFeitran. 
i|. a., in ordrr to perfume it). Bp vanlul nol to rub iIil- nkin loo hiird m it tuny be 
broluin. 

* In exeepUoiial ciu«s thia elevatt.'d pdvia position U budly supported. In i<erliuD 
abort lubjcetii llic diaphragm oiuiDot niipport liic wtdght of ihu vLKiTn wbicb comprcsw* 
it ftod the rMpirntion bocomM rapid and Rt«rtorouii luid tho puUo imgulnr, tJi« fno« 
ej^MMMod ftod pupilH<liUt«d. It ia neaesMrjr to &a»umo the hurlsonlal poailion. 

' Id cxiTcnutly fat nomiMi. Kelly ndviiM's nn cxpbrutory incision at Uie lovnl of the 
umbilieiu, a point wli«it Ih? nbdoiuiiinl wall i* tliiiinpd by rmuou of tbo abfCiwe of 
faltjr Uniie and of inuauulur tiaBuc bi-lwcrn skin and ]writunciiin. 





302 ABDOMINAL CELIOTOMY 

is rarely median and generally opens the sheatli of one of the 
right nuiscles. It is easy to recognize the internal liorder off 
the muscle thus discovered and it is liberated by a cut of llie 
bistourv along the whole length of the internal Ijorder. We 
must go prudently in order not to injure tlie intestines in iin- 
Diediate contact nith the deep surface of the peritoneum. In 
onlcr to avoid injuring thcin, pinch up a fold of the deep layers 
of the wall and then seize the other side of the fold with a pair of 



/ 



L\ 



Fia. 3lH. — iDoiaiou at the ulxlomln&l wall. 

artery forceps and cut between them with the knife (Fig. 465). 
Often the jM-ritoneuni is immediately nj>ened; sometimes the 
same manipulation must Iw repeated several times in order to 
cut through the fibers, fatty tissue and the peritoneum Wfore 
u]>cning the abdominal cavity; as soon as this is ojtened, enlarge 
it at each end with blunt scissors. 

Insinuate two fingers into the incision thus made and Hfl up 
the whole thickness of the wall and then enlarge the pubic 



I 



OPERATION 



808 



extn-mity of Ihc wound, liciiig fiireful nol to injure the bladder, 
and then the umbiUcal end. 

When the <Iiiiipn.sions of a tumor force us to go beyond llie 
umbilicus we prolong the Incision to tin- left in such a manner 
»s to avoid the .susjiensory ligament and ihuii give it sufficient 
diiuensionii. 



pp 


j^i 


^^^hull H M ' -Jo 


/ 


^^^I^b^hbB^^^^ 


"^ 


1 ^\ l^k ^^I 




1 f ■ 1 ■ { 




\ iB^ft m^'m 




o 


m: 



Fio, atiS,— Inci-iim nf itn- p<'riti'iieiiiu btlwttn two focwps. 

Tliis incision usually cuts no vessels of imporlance and it is 
useless to place forceps on all the bleeding points. The appli- 
cation of two sterili:eed cloth compresses on Uie Ups of the 
wound suffice to arrest in a moment all oozing. One or two 
Brterioles at the pubi<- angle of the incision ret|uire to be clamped. 

Limitation of the Operative Field. — The peritoneum Iwing 



304 



ABDOMINAL CELIOTOMY 



upeu. its «Iges are seized witli four forceps, and Iwo wire retnietors 
are inserted, and the cuntetit^ of llie ahdomen are examined. 
Xhis done, the intestines are pressed back toward llic dia- 
phragm and kept there. In or<ier to [>revent a loop coming 
out during the o[)eralion, we commence by iiLserling into llir 
uuiliitii'al angle of the wonnd lietueen the deep face of the 
wttll and the mass of intestines, one extremity of n conipre»< 
uhirh wf phiee on the ahdoininal wall toward the xiphi 
nlermini. 'I'his eumpress assures fur u.s the iinpos.<til>ility of aii 
iiiti*Kltn»l h)op. appearing in the upper angle of the wouud, and 
wt" then priM-eed to place other compresses to Hmil the openitix'e 
lU'UI. The liiass of intestines should be maintained by wann 
enntpM*!Mes, slightly moist, outside the operative field and thus 
iivtitding eitid and truuinalisra. 



I 




Fio. 366.— BtMl wire retr«ct«ra (Hartaaim). 

A (in*l iMUipress is placed in the superior angle of the wound, 
wKieh lilerally rovers and holds back the mass of intestines and 
il rvlends fnnn the incision almost to the promontory. The two 
|«b'r«l n-tniitors an* then successively lifted out and two lateral 
v\U>U>»v»(V( ari* insinuated under tlic abdominal walls in order 
\\\ t»Mt)MMi the iliac fossas. It is often useful to double and 
\ii\<\v tlu'*e nutans of protection of iJie intestine when the exami- 
Ituttmi of (he lesions would lead one to think of the possible 
I MpUHV >»f » fiH-us of suppurations in the course of the operative 
Humip»Ull»>iw- In no case should a compress be entirely intrc^ 
\\\\V\H\ titio the iilHlominal cavity; one extremity should always 
tvturtttt oxletnally. ^Ye thus avoid the risk of forgetting one of 
\\w\\\ til the HtKtoiuen. and there is no trouble of having to count 
lh»*»« IUVS »»»»>• t" ll"' «|>cration and after. The pelvic canty thus 



I 



OPR RATIOS 



SOS 



■ exposed, we prweed lo tin* i>]>('ratit>n we huve in vif w. This is 
more or less easy according to the purpose in view and Uie stale 

Hof the legion!!. In all cases, the presence of adhesions may 
complicate the manipulations. 

Treatment of Adhesions. — Wc may distinguish two great 
groups: influinnuitory and natural adhesions. 

B Infiammatori/ Adhesions. — Adhesions to the wall are usually 

Bpasy to li)>erate. In some cases, however, they complicate the 
Opening of the alxlominal cavnty and one is often puzzlcfl to know 
wliether one is witliiu or out of the periloneutn. The simplest 
thing to do in such a case is to prolong the incision toward the 
umbilicus in order to [leiietrate into a cavity free of adlicfiions and 
thus enable one to obtain an orientation of one's surroundings. 
Tlie niost fretfueiii adhesionn found are those of the ej>iploon. 
\Mien recent, separate them. It is well to clamp pieces of sepa- 

k rated epiploon iK^cause they may be the seat of oo/ing, more or 
less abundant, and for which it is most often necessary to do a re- 
section. When we arc dealing with old adhesion.s. they are too 
firm to permit separation. It is lietter in such cases not to 
p waste time with useless manipulations, but to cut through the 
epiploon above the adherent parts. When it is necessary to do 

Iexten.sive resections, the crushing forceps render great services in 
rv<lueing to a minimum the volume of the e|>iploic ]>e<)ieles. 
Periuterine atlheitions are very troublesome when they mask 
the body of the uterus. It is difrieult to ascertain one's position. 
In such ea.ses look for the body of the uterus methodically as 
_ follows: 

P Commence by the liberation of adhesions immediately 
behind the pubis, at the level of the bladder, and work from in 
front Iwickward. being careful to work always in the me«lian 

I line. We come u[M>n vesico-uterine eul-de-sac and then on the 
anterior surface of the uterus. Continuing the separation in this 
manner, we at length come into contact with the body of the 
uterus. 
We liberate successively its fundus an<l posterior face, .\ftcr 
this wc are in tlie position of » full uterus with oidy the adnexa 
adherent. 

The lilK-ration of the adnexa adhettimis is generally easy 
enough when they are adherent only to the parietal |>eritoneum 





ABDOMIN'Al, CELIOTOMY 



irfat-o of tlic broad ligHiru-nl;. 



It 



ill 



I 



or tn \\w posterior siirtat-o ot llic l)roa< 

currit'd uul in the median line, workinj; IowjirI the sidt*s and pro- 
ceeding from l)flow npwanl. I'sv llie cxtrcniitle-s of llie Hn^'rs 
from the commencement of operation to hook up the adnexa 
from the Hoor of the [mxicIi of Douglas. 'I'his Iil>eration is only 
difiitull when thei-e are adhesions with the intesliiic. 

Intvjttinat adhexionn ought to Ite detached with more ciirv 
because at nil costs we must not o|>en the dijfcstive tract, the 
wall of which, often alten-d by inflammation. Ijccomes inhlh-atiil. 
friable and like a pa.sle lioard: also, if a eleava^- is not found 
enabling se|jaration to ^o on, it is best to use the knife and inc-i.se 
the adhercnl adnexa than seek to separate afresh. In no case 
should one act with force, and sometimes it may Ih> dt>«>med 
necessary or liettcr In leave a pie<'e of tube or pocket adherent 
to the intestine. However much care is taken, the intestinal 
wall may Ije wnnndc4| at the level of these adherent pointtt. If ■ 
the lesions occur cmly in the nmsculo-serous lisitucs. some 
l_#mbert sutures suffice. If the mucous membrane is opened, 
a diMilile .suture, one total and Ihe other .sero-serou.s. is absolutely 
necessar}'. 

V'erj' exceptionally in casc-s of extensive and firm adhesions, 
one may be led to do a resection of the inle.sline. 

I'citiaif adheaioiia niudi rarer arc treated like adhesions of 
the intestine. 

Xatural Adhcxhms. — Umler this misnomer is meant the 
inchision of tunuirs imder a [jeritoneal fold. ']'his inclusion is 
seen particularly in Hbromas which ap|iear on the antero-lalerid 
portion of the inferior sej^nicnl of Ihe uterus and, developing below 
llic serous layers of the broad ligament which they sejiarale, event- 
ually thev conic to lie under the iKTil<ineum in contact with the 
iliac colon to the left and Ihe c*'cuni lo the right. The anatom- 
ical disposition of the parts dietat<>s Ihe tine of conduct in such 
caM^s. Make a circular incision of the ])eritoneum near the base H 
of (he lumor and attach to the inferior lip of the inci.sion a small 
hemostatic forceps, then scjMiratc off the serrxis layer an<] lie 
careful to remain in direct contact with Ihe tumor. We thus avoid 
wound of the intestine and above all of the ureter which is more 
particularly exposed in these cases of tumors included in the 
broad ligament. 



t 




308 



ABDUMINAL CELIUTOUY 



corresponding to known nnntoinirni data, it is easy to know at 
what points one should place Uie ligatures. With tlie exception 
of the uterine, utero-ovarian and some funicular arteries one has 
only to place a few ligatures on blet^ding poinLi corresponding to 
sccondarv vessels: the only important point is never to place 
forceps on hiindly and always to see what one does. 

Peritonization.— Excision aeeomplished and hemostasis se- 
cured, it is necessary to peritonize the rawer surfaces of the 
true ]>elvis by making an exact suture of the peritoneum inclu<l- 
ing in a continuous suture Ihe ligatures and rawed surface. This 
is done by a curved needle in a needle holder. \Mien the surfaces 
to be covered are very exten.sive or where the peritoneum b 
inflamed, tliickened. Friable, and i« easily lorn with the tight- 
ening of the suture, to use the expression of Chaput. we have a 
veritable transverse [mrtitioning of the pelvis. Suture llie 
reclo-vesica! peritoneum to that which covers the pelvic colon 
and the suiwrior part of tlie rwtuni, isolating large [jcritoneal 
canly. the operative field which is left in conimuniealion with 
tlie vagina (Fig. 267). 'J'his partitioning olf. as in all ]>eritoni- 
zation of the [)clvis, is carried out very rapidly with a curve<l 
needle in a needle holder and threaded with Hne catgiit; this 
method a|i|iears very su]>erior to us. as regards facility and 
nipidity. to the suture with Reverdin's needle which my Parisian 
colleagues still employ greatly. 

Examination of the Appendix, -Before closing the abdominal 
wall it is always of advantage to draw in the cecum, to examine 
the appendix, and if it pi-e.senis any lesions to remove it at once. 
The sysleniatic removal of the appendix has liecn advised by 
many o(M-'ralors in all cases in which the abdomen has been 
opened for a lesion of Ihe gj'neeological order.' 

Closing of the Abdominal Wall. -A final abdominal toilet 
having been done, the closing of the abdominal wall alone remains. 
It is well to lower Ihe inclined plane and sec if there is bleeding 
in the pelvic cavity when the patient is horizontal. This may 
occur whereas it did not exist in the 'IVendelenburg {wsition. 

' Kelly UM* the itluliimitiAl ojionliiK to vxplnn' <ithrr n-Ricnii. He li«a bucn mb\m not 
only to dUeovcr appendicular Iv-uoiii Imt ul-iua iiiovatik- kldiM'v. liiliiiry ealouli. oratvnl 
iMtoiwftnd evcnttnyiariolunuir. < Kelly. ICxpluratioii AHHiio'lfunut (oi.-v<>ry celiotomy. 
jiltdit^ ATriM, ISQif, p. TS4.I Wc< Ii<>tl4'vc tlial l)ii< «yilrma1i<i atidoDiitial »iilorallaa 
Is ioferiur to k dtccIm exuniiiation iwBocitttcU wiUi > inoUiadicHi inhrio^Uon of Um 
pfttirat before me opcrnliun. 



« 




OPERATION 



309 



rCow remove the compresses that protect llie intestines. The 
intestines are al)o%vc(l to come buck into tlie pelvis and then the 
epiploon is sought and it is spread out in front of the intestines; 
in order to isolate the pcri-int«stinal serous membrane from the 
I operative fieUI and prevent any secondar}- intestinal occlusion 
due to a kink of the transverse colon which has fallen, at the 
moment of the pelvis being raised, into the diaphragmatic 
concavity, and remained in that abnormal silnatinn till the 



/.(' 



1 >j 



!)'Aj/i/'' 



■.i 



Fic. 26S. — Suture rn rriii*«e. 
The parU sre badly oppaattl 
and tM Kpoaeuro^ in folcTvd up 
between (bo iuumIm. 



Fid. 260.— Suture " Tlio 

|>arls liin-r 't-'-ii "'HI i, i prri- 

tlllieUTll 111 ]|.T Iti ■li.'lJIli 1;lil .-li 1 IIS- 

cle. uml iij"-iiiuui'j-(' tu Lqnini. ni'.ii-i . 



patient is in the horizontal position. Each surgeon has hts 
own way of ciasing the abdominal wall; to be honest, the manner 
is of little importance, provided that the suture remains aseptic 
and rctaiiia aimilar parts inconneciion. 

The suture may be emiiloycd either in on* plane or teveral 
pianes. 

The one plane suture may be done with the aid of large silk- 




Fio. 270. — Necdb with hundlc (Doyen). 

worm-gut sutures, of large silks or even better metallic sutures 
(silver wire, or sutures of aluminium bronze). 

The suturing excites nothing s|»ecial. It is important, how- 
ever, to see lliat the needle does not es<'a|>c the muscle and 
a|H>neurosis, and that it is inserted as near as possible. 

Belter than all descriptions. Figs. 468 and -ififl show the points 
where the ikhmIIc should traverse the difTereul planes. This 
method of suturing lias for its object the prevention of the peril- 




._:" _ ZLi- 7':-MY 



Ms- ~ lips of the wound and that 

" ^~-r Tires whieh would embrace 

:r-^ iT^ phiced 2 cm. apart, and 

:—- lie provided with a handle. 

■'- aeai later and take care that 




I'm. 272. — Hugcdora'p needles. 

.. ^ > ■:^;ther intestine nor epiploon 
•^ 1-': inserted, some superficial 




IX*.- -■ - '.Vvi'ii^ in-iilU' Imlilcr. 

-rs e> *:v plnrtHl iK'twecn them in order 






,, «.nft «•"•• "'"**' *"''' ^''*' l'<'"tf"Oum, 
'*■ "".""^^^x UvtT and la.-^tlv the integuments 

"•-''^* ' ._ ....... wilt 



.i*-' 



,^ <vtti»n or catgut. 



We use catgut sterilized in alcohol under |)ressure for the 
suture of the iHTiloneum and lightly chroinicizcij catKUt for ihe 
munrulo-ajfonfurotic layer' and silkworm j;ul for Ihc skin. We 
do a continuous suture of the peritoneum with one of Hage- 
dom's ne*'dK's held in the hand interrupting the suture after 




Flo, 2 74, — Tlie euniiniiouh v'"' i>l 

fuiure in (iiil»li«d. Butun: uf tlic riLu.iiili>. 
feponeurotio wnll. 



unti •ii|>i I III 



< ijifiiiciiiiK Hiitiiri.- tilt'i.'[. 



e%-ery four or fi%'e insertions. For the .suture of the more difficult 
niusculo-a]>oiieurotic hiyers we use a so-calle<l fistula needle held 
with a needle holder. We do a enntinuous suture taking up all 
the thickness of the lunseulo-aponeurotic layer, heing careful to 
interrupt the suture after every seconil insertion (Fig. 274). 

■ llie eatitui, Hl«rllii«d in iikoliot iiiukr jireHuro u ati«urbcd v«ry quioltly [n 5 or 
(Uyn, whiln cbiumicucil ontRiit lakK nboiil 2A to 2l( ilny* to iwuirb.' It ja particulArlir 
um(u1 for •iiitin- uf the n>iti<.tnnt jiart o( rli« wall, the tnuaoUii Aud upunetinnM. , 



OPERATION 

tt lung tinx^ ago by ChnHsnifjnac. takrn U|> by Ihr American surgmns and 
K^'oiiitncnclocl by Poxzi. It is rltmt- wilb u v<'ry Hnr .itiluiv nn<l » Hai^dorn'x 
nwdlf. sbort and curved. The superior angle of the wound is fi.ved. Each 
«ilg« <if Ute wound i* sclzeii with di.s!>i-cling forrep.'^ sliglttly put on ten.tioR, 
and pclrnvcrled. One forceps is held by the surgeon and (he other by his 
awiistuiit. The needle jienelratejt at first about a centimeter above the nuiind 




>C 



Flo. 279. — Law outurc left 
looae (Roggere). 




Flo. 2S0-— I.aoe sutur* 
drawn tight and liod 
(Koggers). 



or at the side, near the an^le, and then coniplelrly IruverNCA the skin and 
comes out on the wound bringing with it the suture which is drawn up 
until stopped by tJie knot. The ncfiile is then rngsg<Kl in the *kin of the 
op[MJ»itc lip which it traverses, comes out, etc. (Fig. iifi). At the extremity 
of the wound it perforates completely the skin and is (iniiUy knotted. , 




Fifl. 281. — Suture in fiKur«-of-!i. 



7'A« tiUure by duublint} »/ the iifHnirurom's which we usvil for a long time iu 
curing e^■cnt^ations with extensive se(iaration of the recti muscles, is 
cornr4-tly practised by Noble. After uniting the pcriloneiiiii by ini abMiHtalilc 
catgut in continuous suture, lie lakes some ehruuiicized catgut and unites llic 
aponeurosis of tlie Irnnsvertalis and rectus with u eonlinuous suture. 'Jlien, 
hnnng arrived at the extremity of the wound, he juisses the same suture 





314 



ABDOMINAL I'ELIOTDHTV 



throiijiEti the nnterior layer of the apnneiirnst!i which br- siiliircs to tlint <if the 
o|>|>OMlr «i(k-. ihuH xu|H-ri myosin); one of the sides oti (hut of l)ic ollirr. 

The lace .4 lit II re as c»rri<^<] out hvKof^gt'rs.if it oiniiriHt-.tllii' thrcr pldtirsj 
o( titc wull, brings the \Miin into accurntc apposition, antl may be jn Minicj 
cii.w.4 of repenli-rl c-cliotoiiiviii)tii-il ntxil unlat-cd like ii (*or>(-l. One liaKunlyj 
to eut the suture below the knot at the pubic extremity of the wourirl. 

The figure-uf-8 suture give:* u good iipiiiMitton. It is usually madr ta\ 
comjirisc the three planes (Fig. 281 ); personally, when wc have re«-<>ur.'«' lo it. 
wc do a coiitiiiiiniis eatgut in the |»orineuiii and imly pla«v the ligurf-uf-8 in 
the in usculo-a]>u neurotic sheath and skin, uhing silkworm gut. 



^d 



M 



'/ 



^. 



h 



Fta. 283. — RutiMv i>f tlio ubilominHl wall wiUi- 
oul IiurltMl tutum (inwrtloo of •uturoa) . 



PlO. 3S3.— SulDM ofttie bIi. 
domiaal wall without l>url«<l 
suluroa (opcmttoa ivriniDaleJ). 



1 



Jt>ne«co inKfrln n tingte row of rnrtal futurcn itf a V-xhnpc who«e rxiremtlks 
come out through the skin, tlie loops comprise the two ileep aponeumsea, the 
recti muscIcA, the two anterior aponeiirrttic .Hhi.-iilh!> without tmiehiitg the 
skin of the opposite side, 'llieie are tied on a roll of gaUKc. Some eompte- 
Rtentar^' silkwurui-gul sutures coiii|ilcte the ruliiiK-ous apposition lFig». <8l( 
and 983). Gauthier emplo\'s Ihr- jKwing machine suture, I 

Anftnn'i suture Is a little s|H-cinl and is easily undcr>t(Mid by a glance at 
Figa, 98J and !{S<3. It is to be noted that .Vmatin. instead of making an ■ 
exactly niediim incision, splits the anterior aponeurosli of the right rectus \ 
laterally; presses back the internal lip of the aponeurotic incision ami tJien 




OPERATION 



315 



mcfNirntos tlic muscles und o])€nit the peritoneum in tlir medinii tinr-. In thi.H 
vrav the aponeurotic iDcision is itppo-sito intact diuscIci* which diminiHlics 
tlic risk of eventration. 

Drainage. — Durinjj the last fifleen years there has lieen an 
effort to restrict the domain of drainage; we lielievc tliis to be 
wrong. Ccrlainly the pcriloncuni has great powers of absori>- 
tion and very real properties of defense. The J in prove nients in 





Fia. 284. — Sevitiit ntBohliu) siiturc. 



technic, notably thai of [jeritonization of the i>edicles, have phiced 
the |>eritnnenn) in a favored po.sition to engage the struggle with 
an infective process. We wish to show that drainage not only 
presents no i neon von ietu-c but notably ameliorates the operative 
results in a certain number of case-s as we have had occasion to 
show in an analy-sis of ours on lOOO cases of consecutive 



celiotomy. ' 





Pto. 2S5. — Anwnn'B eittun uatled. 



Fia. 288. — Anwan'> eutiiro tied. 



In every operation ronducted aseptically and concluded with 
[icrfect hemoslasis. drainage is of no use. Hut it is indispen- 

' nATtauuin «nd Moticer, Abdomlnftl Dniiuip In Oyneeolugy In 907 ConMctiliv* 
OeliotomiM'. Ann. dr Gyn.. Pari*. 1910. p. 329. 






316 



ABDOMINAL CEUUTOMY 



sable when for sonip rea.ton or other there Is a fear that (here 
niuy have been infection of tlie i>elvic cavity or if one fears 
Ihc production of either a serous or hemorrhagic oozing. 

That is to say that drainage is indicated in the course of an 
'(Operation where a suppurating pocket has been rupture<I or 
wiere a diseased intestine is found or when one is foreed lo 
leave in the abdomen a fragment of the inf)ame<l pocket. 

It is even necessan- when hemostasis is not perfect and the 
peritonization is not complete and where surfaces remain cajwhle 
of oozing. 

From where should one drain? Some <lniin by the vagina 
and others by the lower |Mirt of the abdominal wound. These 



'V 



Flo. 387..— AbdoniBkl drunitse after totdl cikstration: the omentum (»IIa bk« »b 
■proD In front ot tbo mMi o[ int«MliiM and Uiim iwlatM tbo dniiu^ uea. 



I 



two methods have their advantages and their defenders and both 
iippenr to give good results. The important point is to drain a 
limited cavity. Also at the moment of insertion of the drain 
bring all the altered intestinal surface into contact with it. Iso- 
late the pelvic colon and the great omentum, folded d()wn like an 
upron, and the lai^ i)eri-iuteslinal |>critoncum from the drainage 
nrru in the |]elvis. M 

'Hie rapitlily with which a<lhesions form suffices to isolate 
our infective area almost immediately and there is no fear of 
infective complications developing elsewhere in the abdomen 
tFig.«H7). .... 1 

Each of lliese methods has its indications. Wlicn* the 
uleniN has not Iteeii completely removed, wc <lrain by the uh- 




OPi; RATION 



317 



I 



domen. The reproach levelled at this method, to the effect 
that the exudates cm the pelvic floor arc not drained oiT. Is not 
founded because there is always an intraahdoniina) pressure 
oppOjicd to the force of gravity. A large rubber drain in the 
inferior angle of the wound and fixed by a silkworm gut assures 
tlie [>crfect evacuation of fluid without aspiration. We prefer 
this to the glass drains which may break or exercise dangerous 
pressure on neighboring organs, and to gauze drain.s, biH-au-se 
the removal of these Inst is so painful; aTid if the drain is not in 
contact with the part that oozes, it may act like a cork and 
imprison Uic exudates. 

During the first 24 or 48 hours the oozing, sometimes abun- 
dant, obliges us to renew fairly frecpiently the flressing. The 




Fill 2$8 —ViiRJnftl clruDoge. Alongetde the ilrajo In tbe vftEii'^ >■ a icniite wiok. 
The drsinai!!^ •ri'A >* inolntcd from the hj>rgc pi-ri-inii'Btioiil acrDUR iiiotiibriini- by b Mitun 
unilJng llic pclvi« culon to the retro-vcRienl pentoncum. 



drain may lie drawn out in aseptic operations as early as the 
second day. To avoid the entry of omentum into the lateral 
orifices of the tiil>e, it is well to rotate it before drawing it out. 
If the uterus has been entirely removed and an exact peritoni- 
zation has not been carried out and one has had rei-ourse to the 
partitioning of the pelvis we drain by the vagina. We fix the 
extremity of the drain to the edges of the incision with a non- 
chromicized catgut (Fig. 288). 

Drainage by Gauze. Tliis Ims hecn parlicularly recomnirndH by 
Mikulicz. wliM u[i(thI<'(I in llii.- f<jlluwin|; tniiiiiu-r: IIv tuok n piccv of slpril- 






3t8 



ABDOMINAL CEUOTOMY 



iu<l Knutc. squiiK in slinpc, ax lnr>;p its u pocket hnndkrrchirf. inlhi- c^iitrr 
of which is fixed a long and strong silk. Fold the gau/e like a cune. and »riz« 
th<^ end with b pair of forceps and push it lo the limit of the operative am. 
Introduce into ila interior n series of wiekM in order lo fill it and la lanifmn tha 
jietvis. Take out tlie wicks in 4S hours and iJic sac- itHclT on the fourth 
fifth dav. 

Some Murgrons comhinc the gauze wicks and drains;;^ tulies. UMng on« 
of Mickulicx*s >ar» in whirli (hey place ii drnin and at the Miinc time w>uifl 
gauze wieks; otlicK simply introduce a drain and place amuod it sonic gniiM 
wicks, which lanipnn the raw aurfiice.4. All Ihi* procodurc.i were good when 
a hemostatic packing was as neeessarv as a drain, hut now hcmostasis niiiH 
be ]ier/e<H bcf«n> the wouixl I-* clowd. 

In Ameriea a cigarette <)rain is used consisting of a ruhher lube contain- 
ing a gauze wtck. 

Lavage of the Peritoneum.— Some gynecologists still recom- 
luvncl Uiviujc a} the i»rriUmfum in cases where the njieraticin has 
been prolonijt'd, in those where it was necessary to drain off 
(Ichris, cystic fluid, etc. The inlroduclion of a certiiin quantity 
of norma] saline, at a teini)eraturc a little hiffhcr than IhnI of 
the body, would have the advantage, according to lliem. off 
waNliinf; out f<irfi^n bodies, of iiclini; as a goncrnl stimulant in 
shock, of diluting toxic suljslances and favoring leucocytusjs. 
Personally, wc have never had recourse to it. s«*ckiiig, on the 
contrary, lo perform the oi>eration in a limited cavity and 
greatly ])rercrring. in cases where il is indicated, lo combine 
drainage with large subculaneuus injections of serum. 

Dressing. — The dressing is in no way out of the ordinary. 
.\|)|)ly compresses of sterilized gauze tu the wound, placing, if 
there is a drain, a certain number of folded compresses about it. 
Alwn'e the gauze i)lact' sterilized livdrnphile wool, then nrdinnn," 
wool and Wndage with flannel so applied as to exercise an elastic 
compression on the abdomen, to immobili/e the wouiiil and loJ| 
protect it from external shocks and to maintain a constant 
temperature about the wound. 

If the operation has I>een a little long and if the {witient has 
lo«t a considerable quantity of blood, it is distinctly indicated 
before her removal to her bed to inject with a can and a fairly 
long rubber tuW. 3 to 500 c.c. of saline solution in proportion of 
up lo UWU. 



I 
I 



I 




OPERiXTIOX 



319 



<\ 





t'lij. SSi". — InolHion in tm»iaviT»r oelini'iiny 







Fig. '2UCI. — Tbr cutanc-o-niioocuTDtic Hftp is nuseil. 



S20 



ABDOMIXAL CELIOTOMV 



B. Transverse Celiotomy. 

If tlicre is not a largr tutiior. no suppurative lesioii-t. n? 
special o])enitive diffictillics, we may siiltstitute for the nie<iiaii 
vertical and meiHan incision, the transverse incision. To llic 
suprapuliie traiLsverse incision, ^'iierally adopted by the German 
gynei'ologists. ne prefer a curved incision with its summit just 
approaching the jtelviii and the extrcniittcs mounting laterally to 
the limit of the region of the pubic hair. 

After incising the anterior abdominal aponeurosis, wc raise 



1 ^v 




Fis. 291. — 'Hie periloiieuin is ineispd vorttcally itfl«r rclrnctioa »r th* recti. 

the Hap formed of skin, subcutaneous fatty tissue and anterior 
atKloniinal aponeurosis, j^lacing forceps on the numerous lilee^l- 
ing points. From this [Miinl llic oiKTation proceeds as usual. 
The recti muscles are se|>arated in the median line and the fascia 
Iransversalis and peritoneum are opened vertically.' 

Wlien the inlraabdonjinal operation is finisheil close the 
abdomen by suturing the peritoneum vertically, then the I'ecti. 
then the aponeurosis transver.sely and liimlly the skin. The 

' KOMner *tictc<-*l«i), with & {lurpoM punlv Mionn-tlc. Ihi- IruiNccrac miUincoiM inci- 
Bioo. He nuMHl the nkin Mud Uifq the ■tihculttncoun faUy tUouc. Biid incUtd Um 
■■(uMDkHApoBeuiotio tnll vertically. Efkniiomtiol niodfficd Uii« opcntion hy oulUng 
Um ftponauroids tT«MT«niGly Mid ^rparutinf- i\w ihumIm vertically to a« to obtain » 
more aolkl wall IJ. PfnDDi-nntiol, Tclvr Air Vorthcilr den supnuymphydrcn Fumvn- 
qtlHSohiulU for dio Kyn&kolotciiMihon Krvtiolomit-ii. ^aitml. kiin.'Vorlr., 1900.) 



AFTER-TREATMliST 



321 



'Rnfa^e of lliLs oiu'ration is that the L-icatrix is hidden l»y the 

ic hair and also that it leaves a solid wall us the lines of 
sutures are in two [ilane-s re('i]>rneull_v perpendicular. 

The inconvenience of the operation is that it lasts longer, 
requires a more [lerfecl antise[»sis, and thai it gives only a liniiled 
sphere of action. The last consideration is improved by the 
curved incision we advise in preference to that employed hy 
the Qennann. If one requires a hirj^er sphere of action, prolong 
the extremities upward and outward, so as to have a flap with a 
liroadcr hase which may he raised higher and thus enlarge tlie 
space between the two recti. 

Rank'nheuer employs often a Inrtfe incisuni convex I>elow, 
extending from one iliac spine to Ute ot/ier. and cuts through the 
large recti muscles above their in.serlion into the symphysis ]»nbis. 
This incision, which gives a fine working space, diminishes tlie 
solidarity of the wall. 



h 



4. After-treatment 



When the <Ircs.sing is finished the patient should Ik* inmuHli- 
ately taken to her l>ed. which has lieen warmed. Use hot water 
hotlles. Do not leave Ihcni in contact with the skin as the 
luiesthetir.eil part mav be verv badlv burnt. 

It is essential that either the chloroformist or experienced 
nurse remain at her side until she emei^s from the anesthetic. 
Before even the awakening is completed, inject into the intestine 
with a long cannula a certain rguantity of artificial scrum or even 
inject it subcutaneousiy. 
P The patient is maintainc<l for some hours following the 
oj>eraUon with lowered head, and knees semiflexed over a 
|>illow. This horizontal position is useful to comlwt the effects 
of acute nuemia, collapse, shock and also, in a certain measure, 
chloroform vomiting. Hut it must not l>e too prolonged. As 
!iO»n aa she comes out of the anesthetic steep replace the pillow 
and cause her to breathe deeply an<l in a word |)roduce a series of 
|Q-mna.stic respiratory exercises. The most complete calm should 
reign about the patient, leaving her at fii-sl in semiohseurity, 
while assuring ones<'If of the ventilation of the room in order not 
toliavean atmosphere full of chloroform vaporexlialed by the lungs. 




322 



ABDOMINAL CELIOTOMY 



If pains still persist give a little morphine or heroin sub* 
cutaneously (I/i or l/'i cm. repeated as required). In the 
evening, if the chloroform vomiting has ceased, commence to 
give lightly alcoholized drinks (cham[>agiie or grog): on the 
following day give milk and on the day folloning a light soup, 
reiurniiig in .short to a normal dietary very quickly. 

On the day following the operation without waiting, as before 
for the patient to complain of colic or nicteorism, insert a spund 
into the rectum. The presence of this sound leads to an cml&sioD 
of gas and is a great relief to the patient. Even on the following 
day or at latest the second day give a laxative^ or eucma. If 
some intestinal adhesions with difficulty Itlieraled and sutured 
make us fear for the state of the intestine tlie purgative .thould 
l>e preferred to the enema. 

To the liquid.s given in the beginning, it is necessary to ad- 
vance progressively after the intestinal evacuation to solid food. 
I The stitches are taken out from the seventli to the tenth day; 
on the seventh, if it is a case nith stitches in several layers, and 
on the tenth or eleventh if the sutures have embraced the tissues 
en masse; often the stitches are not all taken out at once. We 
commence with those that are surrounded by an areola of red 
and slightly red and cut the skin. 

If a drain has been used, when shmiUI it be removed? This 
may be done in twenty-four or forty-eight hours, if the o[H>ration 
results are normal. But it is often necessar)' to prolong the 
drainage several days. In a general way, the matter is decided 
by the temperature chart and the amount of fluid passed by the 
drain. 

If the convalescence goes on without incident, the [mtient is 
now Hllowed to sit up in be<l and she is given several jiillows to 
support her. She is allowed to get up on the fifteenth day. 

Then' is no Hxe<l rule to guide us; it is certain that a patient 
having undergone a slight operation aii<l whose abdominal wall 
is accurately sutured may get up soon, but it is of advantage to 
keep in bed those palienls who were much nin down before the 

' TLu Mluiulutiun <>f the iutvsUiuU pcrintttbU U luetul. Voepl ntid H. v Hippel iiutti 
on it and inject immodiktolykftor ths opormtion n milliKmm ot ph^-nnslicinlne. wliicli in 
tTpi>i)trd(-v«ry 3 houn until thobowok move. (It. \:Y\ippiA,Crulr.-Blatl.f.Ch{r.. (DOT, 
p. VM^.) Luou Chunponuiin in F^nooe hM for yoiuti Imutilcd on tho ndvKntacB of 
early movvniMit of tha iatortincB. 



^ 
I 

I 

I 
I 



I 




COMPLICATIONS OF CELIOTOMY 



323 



I 



operation and wlio liavf lust very much Itlood or }tccn (trained, 
or have feeble, relaxed and badly united abdominal walls. 

We are not of the opinion, contrary to many Germans, that 
early rising from bed lessens the danger of thrombi and emboli; 
these are septic complications and we cannot understand how 
early moveiuenls of the operated f>atient.s should protect from 
these complications. Some recently published works, however, 
show that we insUt on a too lengthy inimi>Iiili7.ation of 
the patients and that without going so far as to insist on patients 
getting up in 48 hours or three days after the operation, it is well 
to remove them from Wd earlier than we do. The respiration and 
circulation are thus stimulated and they are placed in better 
circumstances in order to rcassumc a normal existence. 

It is habitual to advise the patient to wear a belt: this is prob- 
ably of no grrat service for thin [>aticntji with soli<I abdnniinal 
walls. It is indispensable in fat patients with 6abby ab- 
dominal walls and those who have been drained. 

5. Complications of Celiotomy. 

We may have a nundter of complications after celiotomy. 

Shock. — Under the heading of shock is comprised a complex 
symptomatolog\' charju-terized by elevated temperature, pallor 
of face and cardio-vaseular collapse; the extremities are cold, 
respiration shoi-t. frequent and irregular; pulse small, fast; 
there is cerebral torpor, an indifferent facial expression, while at 
the same lime the intelligence is preserved. 

It is necessary to get tlie patient warm by all means in our 
power (hot bottles, extra blankets, etc.), to stimulate the heart 
by injections of strychnine, sparteine, caffeine, camphorated oil. 
and the respiration by inhalations of oxygen. IJghtly tap tlic 
face and if ii(H'es.sary do rhythmic traction of the tongue and 
combat the lack of vascular tension by injections of tmrmal 
saline. 

Moat frequently the patient gradually recovers; sometimes, 
however, complications ensue and lead more or less rapidly to 
fatal terminalion. 

Internal Hemorrhages. — If the complications of shock con- 
tinue to increase instead of diminish, we are forced to think of 





324 



ABDOWNAX, CELIUTOUV 



internHl hemorrhage. This niantfesls itself in a certain number" 
<»f hours; the patietit is awakened; she stH'ms as if she were gelling 
well when she experiences abdominal [>ain and the pulsi* becamcs 
small and thready; the face and mucous memhrunes blanche, 
and there is a tendency to syncoi>e, etc. The ultra-rapid evolu- 
tion of these com] >licat ions which come on some few hours after 
the o|H'ralion should not be confounded with signs of peritoneal 
infection which appear later, and who.se course is less rapid. 

In presence of an internal hemorrhaf^ don't wail for thera- 
peutic anodynes such as ice applie<l to the alMlomen. Precious 
time is thus lost and the life of the patient may <lepend ou a few 
minutes saved at the beginning. We must immediately o|)en the 
abdomen, lind the bleeding point, and se<'iire il. Intravenous 
injections of serum ren<ler signal service. 

Septic Peritonitis. — S(;ptic peritonitis commences toward the 
middle of the second day. Vomiting or more often hiccough, 
rise of lemperalurc rfildnc-w of the extremities, acceleration of 
respiration, an abdominal faeies. a small and cracked voice and 
al>ove all the small and rajiid pulse are Ihe cardinal symptoms 
that annoiuice the ap{mritii)n of this complication, llie local 
signs are more variable. In grave and rapid forms the abdomen 
remains supple, [Kiinless and sometimes not ballooned. In 
slower forms the peritoneal reaction is evidenced by a more or 
less acute pain and a luillooiiing of the altihimen mure or less 
marked. Tliis complication is generally fatal. The attempts 
made up to the present to comliat past-o()erative peritonitis 
(secon<lary drainage, continuous irrigation of the iK-rilimeum, 
etc.) do not appear to have given uuich result and the thera- 
peutic treatment remains purely medical (massive injections 
of normal saline, collargol, ele<"t i-ai^ol, caffeine, etc.). 

In h'ss .severe fnrtus after infection, if there is no <Irainage. 
remove some of the sutures and place a large drain in the floor 
of the [lelvis, reducing the intervention to a mininuim. Place 
the patient in the half-sitting position and give at the same time 
subcutaneous an<l intravenous injections of saline, injecting 
slowly, using a long sound into the recliini, iH'ginning eight 
hours after the intervention to give calomel in fracti<uial doses; 
in short, doing the Murphy's treatment for acute |)eritonilis. 

Slight Peritonitis.— In the slight infections characterized 





COMPLICATIONS OF CELIOTOMY 



325 



i 



principally by tyni|ianiles, clevnlion of pulse and lemperature, 
vomiting, complete arrest of fecal matter and gas, the inilicalion 
is to give ft purgative in fractionul dascs every twenty minutes 
a soup spoon of a solution of fiO grams {e.g., 1^ ounces) of sul- 
phate of soda in 900 c.e. of Vichy water, stopping as soon as 
there is emission of gas or fecal matters hy the anus, and continu- 
ing if not sucerssfiil to give (he whole tif the niixinn- irrespective 
of vomiting. 

At llie same time inje<'t three hourly under the skin 1 c.c. 
(20 minims) of 10 per cent, camphorated oil in order lo support 
the heart- By these simple means we often obtain a cessation 
of these eoiiiplicnltons. 

Intestinal Occiusion.^Intestinal occlusion is much rarer 
than the foregoing. It is eharacteri/iMl by vomiting, » complete 
arrest of fecal matters and gas. ballooning with perislallic 
unitululioiLs of the intestine, the preservation of a good Facies, 
good pulse and without elevation of tem|>ernture. 

Iteofien the intestine and explore the seat of the primary 
intervention: generally there is an adherent intestinal loop to be 
found. If nothing of this nature be found, look for a kink of the 
colon; if this ilm-s nut exist, we must make an artificial unus. 

Acute Dilatation of the Stomach.^Acute dilatation of (he 
stomaeb i-selmraeterized by vomiting, an alteration of the features, 
an accelerated and small pulse and an epigastric ballooning 
wliicli gradually extends. Treatment is dii-ccled to the washing 
out of the stomach. Then place the patient in the ventral 
position. These symptoms seem to con-espond to a strangula- 
tion of the third part of the duodenum by (he me-senterie 
pedicle. 

Parotitis. Parotitis resuMs from an infection from Ihe mouth, 
and extending into the gland whose secretion is diminished by 
reason of the dehydnition of Ihe patient and absence of mastica- 
tion. This may be prevented by a rigid Hn1is4.-psis of the nioutli 
an<l early ingestion of liquids. If the parotitis is deveIo|>ed, 
resolution may be easily olitained by the expression of the gland, 
combineii with external applications of hot moist compresses 
and cleansing of the month. When an akscess is imminent, 
open the gland by a small incision tlirectcd parallel to the branches 
of ttic facial nerve. 



326 



ABDOMINAL CKLIOTOMY 



Pulmonary Complications. — Tliese are often seen a-v»wiat< 
witli one of till- i>n'(v<liiig coiu|tlications. ocdusioii or infection. 

They may nevertheless c-orae on independently of these last 
and eoiLslihile of tlieinselves a grave conij)lieation. We fear it 
greatly in aged sui>jects already sufferinf; from a clironic pul- 
monar}" infection, or with caniiac or nnial lesions. Fat siihjtH'ts 
are specially liable to this complication. It may be avoided by 
strict attention to Itiv cleansing of the moulh in pix'venling, dnring 
anesthesia, vomited matters entering the respiratory passages and 
in avoiding carefully exposure to cold during,' and after the opera- 
tion, in keeping the patients silting up in bed after the operation 
and preserving the tnmk vertical during the greater part of the 
day. We advise also as soon as there is the lea«t trouble to 
commence veritable respiratory gymnastics and forcing the 
patient to execute from time to time a series of large anil deep 
inspirations. If the pulmonar}' congestion already exists, treat 
it with rejM-ated applications of dry cup.s, cardial; tonics (cam- 
phorated oil, cafi'eine. etc) and by all known means of stimulating 
the general condition. 

Late Intoxication by Anesthesia, — This has been particularly 
studied in I'rance by Tufher. If .slight, question is evidenced by a 
verv small and transient albuminuria and sometimes hv a transi- 
lory jiuindice; if serious, by a diminution of the quantity of urine, 
which contains albumen, urobilin, bile, sonic acchHie, an excess of 
nitrogenous matter by nervous plienomena (delirium, trembling), 
respiratory {irregular dyspnea), by vomiting which may assume 
the aspect of vomito negro. Generally these symptoms go on to 
coma, and death may follow on the third to seventh day. 

It has been recommended to give glucose and alkalies and 
iidialation of oxygen to this condition. 

Retention of Urine. -This is frequent and nniv W In-ale*! by 
catheterization which should be done with a perfect aseptic tech- 
nic so as to avoid sceondarj- infection and following cystitis. 

Abscess of the Wall. — .\bscesses of the wall are due to an 
infection of sutures which may be due to any insufficient stcriliza- 
IJon or more often to contamination during the operation. It is 
important to warn the as.sislant to keep a sterilized compress 
above the tray which contains the suture material and not to 
touch the sutures more than is absolutely necessary. 



I 





COMPLICATIONS OF CELIOTOMY 



327 



Thc3(C [larii'lal abscesses may come on more or less rapidly 
after operatiuii. In cases where iion-al)sorl)eiit sutures have been 
IIS4*(t it has eome on months or even years after, while the wnuni) 
had lonj; healed by first intention and so perfectly that the ques- 
tion has arisen of a possible blood infection. 

Wlien the abscess is opened, it leaves a fistula which only heals 
after thceliniinalion of the .suture, the primarj- cause of the trouble. 
This elimination of the suture is often s{)onlancous. It may be 
hastened by the cui-elting of the fistulous tract with a very fine 
curette which briujjs out the contaminated stilcli. 

In other cases, it is necessary to produce a separation of the 
tissues in order to remove the cause of trouble. CiK-aine anesthe- 
sia is usually sufficient for this little search which may l>e more 
painful than at first thouf^hl. With the catgut we employ usually 
we are able to avoid all late fistulas of abscesses, and in case of 
infection, we obtain after ojiening of the abscess a rapid cure. 

Pyo-stercoral Fistulas. — ^Pyo-stercora! fistulas arc produced 
in cases where one has been obliged to liberate adherent intestine. 
The suture of the altered parts does not always suffice to prevent 
ihe fistula. This often heals spontaneously. In certain cases 
the fistula j)ersists and it is neees-sary to have recourse to interven- 
tion to close it. 

Urinary Fistulas. -Those arc usually due to operative faults. 
They may occur in bladder or urethra. Wien due to .sectioning 
of these organs, which has passed unperceived, a discharge of 
[Mithognomonic urine takes place immediately after the opera- 
tion. If Ihe fi.stula is due to stricture of the bladder or urethra 
by a stitch or clamp, tlie discharge occurs some days after the 
operation. 

Urinary fistulas, with the exception perhaps of some little 
vesical fistulas, have little tendency to spontaneous cure. Tliey 
demand an intervention which is often complex; we will have 
occasion to refer again to this point. 

Phlebitis. — Phlebitis with the embolus which follows it some> 
times constitutes a serious complication of abdominal operations. 
It results from a slight infection in patients with a defective 
venous system (varicose veins, venous enlargements following on 
large alnlominal tumors), blood the coagulability of which is 
increased (in italients with fibromata, clu-onic affections, anemia. 



I 



328 



ABDOMINAL CICUOTOMV 



etc.). and an insuffidcnl circulation (fatly and feeble heart, and an 
atonic digestive cana!). 

It lias been advised, as propliylactic means, to rclie\*c the 
blood pressure to disinfect this digestive tube and to give citric 
acid. If thrombosis comes on, enveloji Ihe limb in wool, 
immobilize it and place the foot in good position. 

In cas»r of embolus. Trendelenburg lulvises the opening of Ihe 
pulmonary artery and the removal of the clot, a practice which 
one has not often the opportunity to follow, and the efficacy of 
which has not yet been proved. 

Eventration. — This may be imnie<liale or late. Imniediitic, 
when it comes on in lite day followinij the removal of the stitehe.<t. 
It is accompanied by the issue under the dressing of loops of the 
intestines. A curious point is that this complication, in apiH'ar- 
ance ver)' serious, is not, generaiiy s[)eaking. the point of departure 
of any other com])lication. ^Vc introduce the intestines and 
close the wound and the patient is generally cured. This compli- 
cation may be avoiiied by using a material xvhich slowly al)Sor)>s 
(eliromicized catgut), and in cases of suture en masse, only 
remo^ng the stitches late if the general defective slate of the 
pnlient makes us fear a <lclay in the establishment of solid union. 

Late eventration is justifiable in an o{>eration where we wish 
to reconstitute a firm abdominal wall. 




CHAPTER III. 



ABDOMINAL HYSTERECTOMY. 



Stmmiary, — Ali()i>mii>iil hJl■^trrf^UJmy.^'^'y|lt■ of [trorrihiro. — Yurious 
|)rorrdurc<i ill. \iy sopnratiun . H. I>v primnn' rcniovul of the uterus, II. by 
miilinuouK trniiNverse .Hi-Hioii. H. by iitcririt- ht'mimTtion, H. total by tub- 
IMrilont-al drcortirution with primary upciiin^ of the iinslcrior vaginal fornix). 
— Indicitlioiin iiD'l moditii'iitions of 1<-<'hrii(- iii-cnnliii^ In tlu- iintiir** nf the 
lotions (iiifliiiiitnnlion of ndm-xu. fibroiiialA, cancer, |)rola|»»t', jiucrjiersl 
infcdtcrn, uterine rupture). 

Fifteen years ago ahdominiil iiyslcrwloniy was the object of 
numerous discussions; of controversies on the tivatineni of the 
]>edicle or slump after the removal of the orjiaii. Some advised 
Uic lixatioti of tlie iH'dicle to the wound exteriiuliy while others 
re<lucc il into the ahdomen; other.s finally fixed it to the deep 
portion of the anter'or ahdominal wall, 'i'hc relative value of 
these measures was larj^ely iliKcus.se<t witliout any decision being 
eventually arriveil at. 

To-day abdominal hysterectomy has lienetilcfl by the general 
progress of the technic of abdominal o|K'rations. doing away 
with pedicles. isi>late4l ligahires of vessels, peritonization of 
intraabdominal raw surfaces. The operation has become sim- 
plifieil and ex<-ellent in its immediate and remote results. 



I . Type of Procedure. 

The palieni having been pljieed in the Trendelenburg posi- 
tion, the surgeon makes a median incision sufficient to allow him 
to see well. 

Having inserte<i lateral retractors, or a large sut»-pul>ic valvu- 
lar retractor, he fives the pelvic cavity by turning back the intes- 
tines toward the diaphragm and maiulaining them there by hot 
sterilized eluth coni|irc-sse9. 

A rapid palpation determines the connections of the pelvic 
organs and adhesions which they present, etc. 

329 



mSrERBCTOUY 



i the operator brings the uteniv 
ilpiiB it with the hand and using, in 
r*w)lttt*i f6ire|>s or even in fibromata, a cork- 
lo uterus is dra\vn to the outside, a large 




l-'lo. '2\I2. — AWominjil hy stereo to my. 'I'hr iiliTro-ovariaii vcsaclnhm-cbccnciitiioroM 
|i*|«vi>ii n liicituri' .■villi ]iiiir ot fo^^■<•p^. Tho lihiiurici:.!le,thr(mi!ed with » glitch, U.k» up 
Iba round llgameul which will be cut aud tiuO. 

foinjiross is inserted behind it in order lo protect llie intestine; 
this has in all probability l>een done at the beginning of the opera- 
lion. The field of operation is then eireuinscri!)ed with many 
olher cloth compresses, maintaining the intestines well confined 





■ryPli OF PIIOCEDUHE 



331 



pticath them and prevpnting lliriii ciitcrliig the pelvis, wliicli 
accident may arist- in spite of the elevated posiliuii of the pehis 
as the result of n fit of eoughing or effort of vomiting, etc. 

We now proceed to the ligature of tlie right ulero-ovarian 
pedide. To do this, the uterus is drawn forward to the left. 
The operator seizes lietwefn Iiis left thumb and index-finger the 
utero-ovarian [>edifle. raises it and passes below it a blunt needle 
(Fig. 493) llm-aded with No. 1 or No. « catgni. Tightly lie this 
catgut around the infundibulo-pelvie ligament jtist outside the 
adnexa. 

A pair of forceps having been placed a little outside this liga- 
ture, the pedicle is cut through very close to the forceps. With 
the scissors the broad ligament is sevei-ed almast at llie level of the 
round ligament. This segment of the broad ligament is nmseular, 
and preliminary furcipressiire is useless if applitn) to it. How- 
ever, note that before cutting through the round ligament it is of 
advantage to encla<ie it in a ligature, because it generally con- 




Fto. 293. — Bluiit ticciiU-' (Hnrtmann). ThiR needle enabbs iw to take tip the vwad on 
tbo floof of the oscavMion And on iu wall Ity ren^un o( the Acut« aiiK^o "( tho nooillc. 

litis a little arteriole (Fig- i93). It is cut through after having 
first fixtnl a pair of forceps a little internal to the ligature that 
surrounds it. The same procedure i.s curried out on the opposite 
side. 

Of the .six arterial pedicles of the uterus, four are already 
tied. There now remains only the two uterine arterial pedicles. 
They are. it is true, the most important. 

To expose them, we unite with a transverse incision the two 
sections of the broad ligament; this incision passes aiuiig the 
anterior face of the uterus a little above the floor of the vesico- 
uterine cul-de-sac. We then separate the bladder in tlie middle 
line and on each side the anterior fold of Uic broad liganienLs, 
pressing tlic whole forward. The separation of the bUidder is 
generally easy but it is .sometimes nee<-ssary to use .scissors in 
order to se%'er .some rather firmer adhesions along the median 
lioe, tt& to the anterior fold of the bnmd ligament, it is very 




332 



ABDOMINAL HY8TEBECTOMV 



easily •^parated. This separation exposes the ulfrtnt' |wclirK-s. 
n'hich art' i-stilutcd witii a ^ruuviil soumi; thi.s Uolation should )>€_ 
done gently, in order to avoid tearing the peri-arlerial vcnous( 
plexus, a tear of little inijKirtance hut which may become very 




PlO. I'ltl — A'-li'milml li_Vkl<-r<-<il'>i 

mniU b&ve lawn ii«il Mid wvcml . ' 
hu bMD «c|ttmu-tl iiy licnlnra of the i. 



'!'■ (ii-ritaiipuiii alrMtl)' cut ihrniift^ 
jHcrv. 



Irouhlesome and whjcli it is In'tler to avoid. Tlie isolalttl |>pfi- 
ides are then lakeii up with a lihint needle. One lihinl needle 
is of uilvantage in this (Fig 49^). I»eing more liandy limn thcr 
other forms used, as will l>e found in ull eases where a ligatnrt^ 



lo he passed around a pedicle lyinj^ deep in a cavity. The 
tfjill passini liy this iiec*ilc is iiiiinediately tied, a pair of forceps 
placed a little above the ligature and the two uterine pedicles 
e cut through I>ptween force[>s and ligature. 




i. 29S.->^ub(oUl ulidominal bvNlcnictoniy. Aftor ntmorinft a woiI)[o-idi«pcd piece 
n( iiMiut!, the c«rvlx 1h nuw «utured. 

Tlie detnehnient of the uterus now atone remains. 

'riie »ta){e.s of tlie o]>erutiun vary according as it is desired to 
t a total hijHffrectovii/ or to cut across the uterus immediately 
Mjvc the vagina, and leaving behind the vaginal portion of the 
rvix. This is generally known as aubtolal hyniereetonnj. 






Via. 390. — Subtulul alnloniiaitl hy^ttvrvdoiny. Afii>r nriiiov*) of n unlcp-shaitil 
piMWot muscular Uuuo, the PcM-ix uvuturcd: a continuous pcritoncrtlnuturv. Jnicrrupud 
Kt evtry fourth or flitli Milch, burios the liKkluroH pcdiclo* kiul Hit wrvlx. thtu Mwuriap 
a moipWle perilooiiatioa of the paru. 



hollowetl out; all llic^e cut surfaces bleed; if it b only a dight 

oozing, traction force}>s suffice to secure teniporari- hemostasis. 
This operative procetlurv is eurricd out in tbe fuliowinj^ manner: 




The ulerus having been drawn upward and a little l>ackward 
e anterior fatv of the iiltTiis is ineistfl with llic scalpel and 
en the anterior portion of the cen'ix seized with a pair of 



TVl'E OF PROCEDURE 



336 




Kto. 207, — Tolal hprtvrecluiiiv. The BcpkrntUin of tJie bWiler liavinK |r..i i . Ipd 
r floouKh. the vnRinn J* oiwni^ anteriorly: a juiir of Mumux'i forc«|j» Miii..-, tii« 
Icrior Up of tijc Mcr-ctilleiJ buttunholv. All iti&t now renioiiu U to MpftnU Uie vngina 
LTowtl the cvrt-ix. 



irccps and the incision in eonliniied posteriorly until the organ 

complelely severed. As the cervix is fixed li_v tlie forceps, 

does not fall l>ack. Nothing is simpler, once the^aiuputation 



k 




336 



AnnOMlNAI, HYSTERKCTOMY 



is concludetl. tliiin to i)la<'i' h sccoiul piiir of Museux's forceps 
on the posterior face, and then, exposing wiUi tlies<> two pairs 
of for«-ps tlic upper portion of the cen'ix, to excise a wedge- 
shaped piece of muscular tissue and to remove In its entirety the 
intracervical mucous menihrane. All that remains finally is 
two flaps of the cervix in front and behind. 'I'his method has the 



I 




PlO, 29fl. — Total fayslc^octomy. I in • ■ r ■, i\ in drawn through « butIOtitioi« mudfl Lb 

till' [i<.'>!-.Ti< <[ vugiiml wall. 

atlvnutagc of creatiiifj two supple Hups, which adaj)l themselves 
easily, the one to the otiier. for the suture and of doing away witli 
the sometimes diseased en^Ioeervical mucouf^ meml>rane. Three 
catguts unite the anterior and posterior lips of the surface left 
after the section and assure hemnstasis at the same time. 

If it is desireti to do loliil hyaterevlomy, the separation of the 



I 




TYPK OF PROCRDURK 



33; 



pr is rjirried on anteriorly until the anterior vaginal wall 
is readied. It is ofiened, ami llien with a pair of Museux's 
porceps seize the vaginal lip of the incision and complete the 
duiinscrtiun of this canal by a circular incision with sei-ssorii, 
which work obliquely, while the uterus is drawn up and away 
from the side where one is working (Fig. iQl). 

If there are doubts as to the situation of t!ic vagina, we may. 
IS Doyen does, open in the median line poslerioriy, on the end of 
pair of forceps introthiced through the vulva. 
It is then easy to seize the cer\*ix with a special pair of force|»s 
;. 300) tlirough tlie buttoidiole made in the posterior wall of the 
vagina, to draw upon it. and to disinsert the vagina around its 

(wliole circuTrjference (Fig. 2il8). 
The uterus having been removed, a wick of iodoform gauze 
is introduced through the gaping opening of the superior portion 
of the vagina and which latter is closed by a series of catgut sutures 
which ser\'e at the same time to stop the numerous bleeding 
■ points. 

I If it is desired to do vaginal drainage close the lateral bleeding 
Ipurts and leave o[>cn the middle part of the vagina, and whatever 
Ithe operation performed, whether it be subtotal or total hysterec- 
tomy, from that point the end of the ojieration is the same. It 
is necessary to cover the row surfaces witli peritoneum, which 
may be done with a continuous suture of fine catgut, which buries 
laterally the vascular ]>edicles. in the middle the vaginal suture 
or the uterine pedicle according as whether the cervix has been 
.remove*! in iLs entirety or not. 

f When the operation is concluded, the floor of the pelvis pre- 
sents an a)>s<i|utely smooth surface; if one has the oppoKunity to 
study the |>elvic cavity of a woman thus operated on several weeks 
ufterward, one is struck by the complete absence of the adhesions, 
by the regularity of the floor of the pelvi-s; if it were not for the 
ibsence of uterus and adnexa. no abnormality wouUI suggest an 
)peralion. , 

We will not return to the subject of drainage by abdomen or 
ragina or the transverse partitioning of the pelvis by .suture of llie 
pelvic colon to the retro-vesical peritoneum, as we have already 
dealt with these questions in the chapter of celioloniy in general. 




ABD()MISAL HYSTERECTOMV 



9. Various Procedures. 

Hysterectomy by Separation. 

With recognition of the fact that the principal means of fixaT' 
Unn of the titeru.s i.s its continuity witli tlie vaf^Jna. J. L. Fniire 
recom mentis oonitnenciti^ by the separation of ihe iilerus from i 
the vagina by incising it across aljove its vaginal insertions, fl 
This division uf the ccr\'ix uteri, this uterine sejmrotion, is carricci 




Fio. 299.— Hyslereoromy by wpa- 
i*UoD. The utcruD bav'ltiK beon 
drawn upward anil TorwanJ. Uio sois- 
man cut ai-rusB ibc inUunux of liio 
■tvu*. 




FlO. 300. — Hj;*lM*eiomj- by 
NpUKlvon. Theislhmuii ^uU bocn 
divided. Tlio IidHv i* only at- 
tached to tho ocrvix by aa miI«- ^t 
rior strip <if utorin« tisaue. ^H 



out before any oilier niaiiipiilation, and is the capital act of the 
operation. 

The uterus Is drawn out and turned over as nuieh as |>ossible 
on to Ihe pubis. We are then enabled to see Uie pouch of Doug- 
las and 1 he isthmus of the uterus, which is recognized, in general, 
quite easily by the presence of a conslriction corresponding to tlie 
upi>cr edge of the utero-sacral ligaments below the boily of the 
uterus which commences to widen out above the smotith and 
slightly "bombe" cervix. 




VARIOUS PROCEDITRES 



If the- iiti-nis is lifformed liy fibromalous bases, the isthmus is 
less plainly seen, but it may be recognized on palpation. The 
index-finger, inlroduced so as Ut lie on llie fluor of the pouch of 
Douglas, between the two utero-sacral ligaments, depresses 
anteriorly the supple and deprcssible wall of the vagina. If it is 
earried upward toward the uterus, the finger soon feels the pro- 
jection of the cervix: aljout 3 or 3 cm. below this lies the isthmus. 

\Mieii this is recognized, cut it across with stroug curved, blunt 
scissors. Traction on the body of the uterus makes the incision 





FlO. 301. — Uysteroctuiny by Hupam- 

'tion. The riglit hnnd Imvini; prcancd in 

'fthv anterior peri tonpal (^nvpniiic. lifU up 

KOd inak««> pedicle of t)iu broud lif^ament. 



I'lo. 302. — HyHtpn-ctomy by wpon- 
linn. The Inft hand M-uns Ilie brwd 
linnniciil uliik- the ri^il hund altodiM 
B piiir uf furri<^jH to it external la Uia 

ni\tiPXa. 



^ajK* and one is enabled to sec the central cavlly which serves as a 
jjuide Jin<f the division may be conlinucit without fear of injuring 
the bladder (Figs. 299 and auO). 

For the rest, if one goes Wyoiid (he uterus, in the great 
majority of cases, one finds oneself in the vesico-uterine cul-de- 
sac or above it. 

As soon as the separation is completed between the body and 
cervix, draw the former upward: then in.scrl two or three fingers 
of the right hand into the space which separates the two segments 



340 



ABDOMINAL HYSTKREtTOMY 



of the divided uterus, pushing them from behind forward with 
the paliuar surface uf Uiu hiiiid U])wanl. Tlic extremities of the 
fingers come into contact with vesico-uterine cul-de-sac which it 
pushes in. The fingers lie in front of Ihc uterus and )>roud liga-S 
ments. wliile the thumb is behind. In carrying the hand toward 
the right, the broad Hgiiment is picked up Iwtween llie thumb and 
indcx-ftnger and a pedicle Is thus prepared. Nothing is simpler 
than to isolate it by lifting it from below upward as far as its 
pelvi<' inserlion i-xternal tn the adnexa (Fig. 301). 

With the left hand seize the already pediculated broad liga- 
ment while the right clamps tlie |)edicle tliat is afterward divided 
with scissors (Fig. 303). 



Fid. :I03.— HyMwMtomy hy •oparatlo 
Tho uMnu to tillMd to die left and a 



on. Tlip riRlit Itrond liaampiit haa been divided. 
fonvpa tiuliU ili(^ luf I brcMul Ujanient (t'atira). 



Tlie Ht«nis is tilted toward the left and the Icfl broad ligament 
exposed. This is |>ediculated as before and divided with scissors 
(Fig. 303), and the uterine arteries are tied as also other bleeding 
points, and Ihe r)]H.'ration terniinattH] as usual. 

When the uterus cannot be drawn forward, the crrnx w 
divuled in front, an a level with the vesico-uterine cul-<le-sac. A 
pair of Museux's forceps is fi.\ed to tlie inferior portion of the 
bo<ly of the uterus, and then with curvc<l .scis-tors tlie i.itlimus 
is demided from in front backward. It is (hen quite a simple 
affair to bring the interior portion of the body of the uterus for- 



I 




^EDlfRES 



341 



ward and to iitlrotlucc the fingers heliiiu) it. and separate from 
above upward the adhesions which &x it behind. 

Hysterectomy by Primary Excision of the Uterus. 

This protefhire was initiated byVjIIar and generalize*! mainly 

by Terrier. The fundus of the uterus is seized with traction for- 

koeps and a long pair of Kocher's forceps is placed from above 

'<Jown\vard along the border of tlie uterus as far as tJie level of the 



/ 



'X 



X. 



y 



-A* xiJ 



JVfM. 



AUndllr 



•,^-lJ: IWC-i;^ tj-i; 



Fio. iOi. — Uyatcructuiuy bj- continuous tnuuvcrse divinon (K«lly). 

isthmus; a second identical forceps is placed n little more exter- 
nal, along Uie whole depth of the broad ligament, which is divide*! 
between the two forceps. A similar manipulation is carried out 
on the opposite side. The uterus is only attached now to the 
cor\-ix which is di>ided at the isthmus after clamping and tying 
the uterine arteries. 

In place of the excised uterus is an empty space where the 
band may move with ease in an endeavor lo attack the ailhesions 
on each side. 



Hysterectomy by Continuous Transverse SeclioD. 



L on eacD siue. 

I Hys 

^^P Hysterectomy by continuous transverse section, earned out 
W and first described by Pean. is best known under the name of 




342 



ABDOMINAI. nySTEBECTOWY 



H. A. Kelly's operation. It consists in culling successively the 
(is^sues from one side to the oilier, comnieiieieig with the ntero- 
ovarian pedicle, hroad ligament of the same side, uterus, broad 
tigitnient of the other side and Bnishing with ligature; and division 
of the second utero-ovarian pedicle. 

The oj)erjition may he commpiiced to the right or the left, 
choosing the side where the operation seems simple owing to the 
parts being more accesjiible. 

Draw ilie uterus to the opposite side, tie the ulero-ovarian 
vessels on one side, and divide the round ligament; then, turning 
up tlic uilnexft, cut obliquely across the broati ligament a.H far as 
Ihe cervix. 

The vesico-uteri ne periloncum, having been in its turn incised, 
and the Idadder pressed forward, the uterine artei^' is ex[)0«ed 
to view and is taken up on fi blunt needle, very low down and 
near the cervix. 

This is divided in its turn with strong blunt scissors or scalpel. 
immediately above Uie insertion of the vagina. With traction 
forceps, seize the superior lip of the incision which is made to 
gape and then cut ]»rogres-sively the uterine tissue under visual 
control until cut through in almost all its substance. Continuing 
to draw gently on the forceps, one observes that the uterus, in 
tilting, separates from Ihe broad ligament of Ihe opposite side; 
the second uterine artery comes into view; it is tietl and cut in its 
tuni (Fig. 304). 

Continuing the tilling movement, the second broad ligament 
iinfoIdH to our view, the utert»-adnexa! mass only holds logelher 
by the round ligament and the utero-ovarian pedicle, which is 
clainpe<l and dividtti without the least difhculty. 

If in this operation it is decided to do a Uital hysterectomy, in 
place of dividing the cervix, after having lie*! Ihe first uterine 
artery, one proceeds to the separation of the soft tissues, close 
up to the uterus, belwt-en this organ and the lied uterine artery, 
and continues until Ihe lateral vaginal fornix is reached. It is 
recognized by the difference in consi.stence of the tissues. It is 
opened laterally with Uie scissors. 

Seize the incision thus made with a |>air of force|iA, in order 
that it may not fall tuick; then, attaching strong toothed forceps 
to the cervix, it is draw'n upward, while the vagina is divided 



i 



4 




VARIOUS PROCEDURES 



343 



coDi|)!elc'Iy around it with strong scissors which should not 
deviate from uterine tissue. 

This (lisiiiscrtion having been completed, the uterine after)' 
on the opposite side is lie<l and dividwl, and the ojwration is 
conchided as in suhlolal hysterectomy. 

Hysterectomy by Uterine Hemlsection. 

Tliis jjrocfdure has been describc<i and carried out by J. L. 
Faure who operates as foHows: The fundus of the uterus liaving 
Iwen seized with two strong forceps, both of which are attached a 
little outside of the median line, it is divided as far as the istliuius. 



^■N. 



Fio. 30R. — Hy8t*rept«mv by 
hemlMotion. The uterus ia druwu 
UpWKrd by twn fnrocpi nml the 
hunbeotioo in oommenccil. 



/ 



Flo. 306. — Ilymcn-i-iomv by heml- 
Hcotion. The riKliI Imlf iH tho ut«rus 
■Irljkclii'i] nt th« Icwl a( the iiiihiouN i« 
iltiiHri uifwunl. CloiDplitft of llir left 
luitf of tlic uterus (J. L. Kbutc). 



at the level of the vcsico-u ferine cul-de-sac. It is very easy to 
avoid all uterine hemorrhage, to cut exactly in the middle line 
when traversing the uleritie cavity. As soon as the uterine cavity 
is opened, it is sterilized by the a]>|>licalion of a thermocautery. 
The uterus is thus divided into two halves a» far as the isthmus. 





344 



ABDOMINAL HY8TERECT0UV 



One of the halves Is taken up with a traction forwps ncarti 
isUiiiuLs and then with large cun'ed seissors, it is di\"ided at this 
level (Figs. 305 iind 3UC). Drawing on iJiis half of the uterus it is 
made to pivot around the insertion of the adnexa. The uterine 
vessels are approached internally and arc divided after having 
lieen clamped. Continuing; to draiv on the laterally iuclinc<I 
half of the uteru.t, the a<lnexa are then drawn upon and separated 
below. The operation is concluded by tlie clamping and sectjoa 
across of the round ligament, and then of the utero-ovarlan 
Teasels. 



<-^ 



^V 



% 



fA 



"^x* 



K>i 



Fto. 307. — HyatereoUtmy bv hcinU 
Mctlon. Turning down o( tlie rijcht 
hjtlf of tlic uterus. ClAmpiDK of tlie ccir- 
iMpondiAs bnwd ligament which will 
nnr be divided. 



Flo. 3tJ» —Total hfatcMctomy by 
IicmincctiaD. L)isiniiertioa of the raitinft 
in n line with Iho diTid<yl ootvis on the 
right tide. 



The same manipulations are carried out on the other side. In 
short, each half of the uterus is dealt with as in the second half of 
tlie ojK'ration for hysterectomy with tlie continuous transverse 
section. 

If it is desire<i to do tohil hysiereclomy by this method, the 
vesico-uterine cul-de-sac is incised.[and the bladder pushed Imck, 



VAHK 



rRES 



346 



thus freeing completely the anterior Taee of the cervix and tlie 
sujicrior portioTi of the vagina. Then instead of stopping the 
median section on a level with the islliinns. the incision is con- 
tinued right into the vaginul cavity. Seizing one of the halves of 
the cemx with a traction forceps.it is drawn npward and outward, 
the vagina is cut, str(?t<'he<I, and divide<l close against the uterine 
V tissues and one continues as before (Figs. 307 and 30H). 



Total Hysterectomy by Subperitonesl Dccorticatioa with Primary Opening 
of the Posterior Fornix and with Preliminary Hemostasia. 

This procedure owes its introduction to Doyen and reposes on 
the rejection of all preventive hemostusis; it is carried out in 
the following manner: 

The surgeon stands to the left of the |mlient. The uterus is 
thrown down on the symphysis. The posterior fornix of the 
vagina is opened. This fornix is rendered prominent by the 
preliminary introduction of a curved pair of forceps into the vag- 
inal caWty. The finger is introduced into the vaginal buttonhole, 
tlie cervix is rea>gnizeil and taken up with a special hook. We 
prefer forceps (Fig. ^09) to Doyen's instrument. The cervix is 
drawn upward and appears between the edges of the button- 



I 







Flo. 300. — Foroepx to «eiM the oervix tlirouitli the buttonholo in tlio [losterior w&U at lbs 

VDgina. 

hole incUion in the vngina. It is easy to rccogniiur its lateral 
attachments with the mdex-finger of the left hand. A scalpel or 
scissors is enij>loyed to make u division on each side in contact 
with the uterine (issue. Free the lower end of the cervix from its 
lateral attachments to the interior portion of Ihe broad ligament. 
It is raised uj) immediately by traction of the force|>s in an upward 
direction. 




M4 



• -"::zi D'MV 



One 111' 

istlitir 
Icvrl ' 
liiiidi 



■ ■-^i. is rut across with sc-issors 
.-: v:n;; stronjily on the forceps, 
.1 :ie riiiht nidex-finfjer. 
-I IV its lateral vascular coniiw- 
- :. tij introduce the left iiidt'x- 

p-ad UfTiiinent. and then to per- 
■,:n and to proceed to the sepa- 

i :ih the tiiif^er bent like a hook. 




i; ■iivi-rrir:iliciri, Tlic v.iiRimi liiiviiij; U-i-n 
■- \ « liii'li U lIuTi liriiwn upttvini. ili'tiicOiiiii' 



I. iN^istaal ))et\veen thuniharidindcx- 

:i' .iiiuexa am! tlie uterus. 'J"hc tumor 

.. !v '.oft. It .strips itself of its anterior 

nrv'ssifil <itViTs any resistance, then 

.. (■:-. iirnad lifjainent. and Jinally <mly 

,_ ..:c- <'i tliis lallcr. .\ final cut with (lie 

, \ i.\\ i< cauijlit !)y an assistant. 'J'lie 

■r-.Md li*:anient of tlie left side aii<I 

..n'-.:;isi'i of the l>ni;id li<,'anieiits. Two 

»■ '■•.;< in the siin[)le eases. 
, i^-i ar\" drawn inlu (lie vaj^ina and the 
.^ s i'UvmhI willi :i puisc-string sulnre, 
. M.- •% a eontimiou-; uue. 



INOICATroXS FOR ABDOMINAL HYSTERECTOMY 



I 



S. Indications for Abdominal Hysterectomy and Modifications 
of Technic According to the Nature of the Lesions. 

AbdomiDftl Hysterectomy for Inflammatory Adnexa. 

Teclinic in abdominal livsterectomv presents no 8|iecia]Iy 
in tlu* <-HS(^ (if inHaniination uf the ailiii'xa. It is important to 
limit Ihe operative field wlien one is dealing with sujipurativo 
lesions of the adnexa. It is in such cases necessarj' to double 
and triple the rampart of compresses whioh protect the area of 
operation from the general peritoneal cavity. The superficial 
already soiled compresses should be changed in order to prevent 
infection going through to the deeper compresses and then to tlie 
intestines. 

The existence of adhesions, although it does not interfere 
with the course of the operation, may (*(>n)])licatc its execution. 
The freeing of these adhesions is more or less easy according to 
the case. Commence with the least resistant. Generally the 
finger may detach these: iine should be careful to tear them from 
the organ about to be removed: this is the best means of avoiding 
lesions of the adherent intestine. When the adhesions are too 
tight, di.s.sect them with a scalpel or scissors, taking care to cut 
always from the side of Ihe ftrgan U* be removed. We have seen 
how the intestine may be injured in these manipulations and have 
indicatinl the course to follow in such cases. 

With patience and method we arrive at a successful issue 
even in tlmse cases which seemed impossible at first. 

If the adhesions arc so numerous that they render the pelvic 
oigans unrwtjgnizable. concealed by adherent great omentum 
and intestine, in order to find our whereabout.s we must first 
look for the bodv of the uterus. To do this, commence bv 
sejKirating the j>arts in the median line behind the pubis; one 
then comes across the |»osterior face of the bladder; in liberating 
it little by little, one infallibly finds oneself in the vesi co-uterine 
cul-de-sac. and then to the anterior face of the uterus, l.ittle 
by little we free tlic funtUis nnd then the posterior face of that 
oi^n. This having been done, we are masters of the .situation, 
and it is easy to free the adnexa. All that now remains is tl 
hysterectomy, following the method we have related. 




348 



ABUOMINAL HVSTIiltECTOMY 



'llie special procedure wp have dewribed may sometimes l>^ 
of service, in (mrticulur that of continuous transvcrst- sc'ctJon. 
which is specially indicated in those case-S of inBanitiiation of the 
adiicva where the parts ai-e easily accessible on one side but not 
on the other. Commence the operation on the easily accessible 
side and one linds oneself .idinirabty situated to attack the ven.' 
adherent adnexa from below upward and from within outward 
on the opposite side. 

If the cervix is almast normal, it suffices to hollow it out and 
do a subtotal hysterectomy: if on the contrary it is very diseased, 
it is illojricul to leave it, and we shiruld do a total hysterectoiuy. 
This is even indicated when the raw surfaces of the pelvis cannot 
be clotlied with peritoneum and if possible to terminate the 
operation by a partilioninj; of the pelvis above the area drained 
by tlie vagina. 

Rwoeiitly Brtiltncr. after rt-moving llit discnDrd tubes, seek* « iimr* con- 
sorvstiv€ operatii>n.' Hi- viils u weilge fnnii Uir fundus, prcscning the 
round ligniiicnts •xllli csrc. Tlipsc incistoos an protonged on to (hr nnlerior 
sud posterior .surfuc's itf tlio broaii ligitmfritM. AfU-r liaving mado 'm 
the aiedian line a hctniscclioo of thr wedge already eiit, )ic kciw^ oiiv of the 
halves of the fundux of the uterux n-ith a jmir of Mu»cux'.s forceps and 
detKchejt it with seissors. 




Flo. 311. — Romovml of thn tiibra nitli [inrtin.1 prcwrvktian of the utcnii Bod ov»rie> 
(tbi) dotl«il line ini]ical«H tlie Iticision). 

Having n-aohvd the vomua of the iilrrii!*, he cuis Hn<) chtmpti the uterine 
arterv and il^ brnnehcs, excises tlie disea^ied tulic and if necessary on one side, 
thv IuIk- and ovary. He conchides the excision hy ligature of tite infundi- 
bulopchic- hgament. Similar manipulations arc carried out on the opposite 
side. 

The uterine wound is closed liy a deep musculo-tnucous-menilirane 
cutout suturv ari<l then u second «eru-»iTuM» itulure and if need be a tliird 
one. 

'Autwrt. Ckinocniln^ t1i« ExtirpaUnn of Dllat«n] Adnrica vriUi Tramvcmw Exa- 
rion of lh« Uterui by Bouttncc'a I'roceduM. /Icdm oitdiatle tie la Suitu romanJ4,lVO0, 
p. 78. 




INDICATIONS KOR ABDOMINAL IIVSTERICCTOMY 



349 



^P The operation boin^ terminatt^, tlip surifiMin RnAn himself in presence of 

I a little tit(.Tii« ucTOiiipHiiied bv iin oviin,- uikI sotnv fraffincnts of Ihr one or 

both ovaries whieh have Iw-en preserved; the round ligameDls still remain. 

the n-)iiliiiiiKliip n{ llic bladder and iilfriis Imvc nut boen in any way elianf!""*]. 

and the broad liganionl.t have only licen saeriticed along avery ttniilcd extent. 
^P The menstrual function can go un and the [lationt may not regard IierM-lf as 

•iefonned. 




Fid. 313. — 0)i»ratioii linlshed. 

As f>r u possible the uterine suture is covered with peritoneum and if 
need be it may be covered over with the loop of the .si^^oid or even ont may 
be forced to do an anterior abduniinal livitteropcxy on the posterior face of tlic 
utenj5. 

Results. — The mortality from alKiominal hysterectomy is at 
pffscnt verj- low and is always bccominj; less. 

Our first results show four deaths for 104 operations or 3.35 
pt>r cent.; our second n'siilts showcii two deaths in 1.39 rases 
or 1.43 per cent. If tlie le,sioiis present degress different of 
seriousness on each side, we rcestalilish one of the hroad liga- 
ments following our general method and confine ourselves to 
parlilioning olf the opposite side of the pelvis. It suffices after 
having closed the hroiid ligament on the less diseased side with a 
continuous catgut suture, to place a drain in the vagina, the 
extremity of which lies in contact with the raw surfaces on the 
opposite side. then, taking up the needle again, we continue the 
suture l>y uniting the re<-tt>-vcsical peritoneum to the anterior 
face of the rectum, and then to the pelvic colon until all the raw 
Kurfaccs have <liMa)tpeanMl from view tinch*)' llie sutun*. 

The immediate res}ilh are exeellenl. 'J'lic remote results nre 
none the less sali.sfactory. We \vill return to this cpieslion when 
we deal with treatment of inflanimation of the adnexa. 

Abdominal Hysterectomy for Fibroma. 

In the Instance of lihrorna, the cxeeiition of alHloininal hy.t- 
lereclomy presents a certain number of |>ccttliaritics. 



360 



ABDOMINAL IIYSTKRE*TOMY 



Opening of the Abdomen.^Tlie aixlominal wall should Ite 
opened with caution. lis loo rapid division may injure the 
fibroma and opens one of the great venous sinuses which spread 
about its surface; it is a complication of no fjreat importance, but 
which nevertheless may give rise to a very troublesome but nou- 
dangerous oozing. 

A prudent incision enables us to escajte wounding the btadflcr, 
to which one is exposed in cases where the organ has I>een drawn 
toward the nniliilicus liy u fibroma develope<l below the vcsico- 
uteiine cul-de-sac. We must fear a similar ascension of the blad- 
der, when, after incision of the mu.'M'idi)-aponeurotic layer, one 
comes into contact with a thick fatty layer, which leads one to 
think of that which lines the bladder in front. In such a case, it 
is recommended to work toward the umbilicus in order to open 
the peritoneum above the dangerous zone. 

Extraction of the Fibroma. \Mien llie abdomen is open. 
rapidly explore the tumor in order to ascertain its connections and 
mobility, increa.sing, if ncei\ssary, the incision made in the wall.' 
Then draw the fibroma to the exterior with the hand or with a 
large pair of Museux's forceiw, a proceeding of no difficulty. 




Fio. 313. — Large piJr irf Mii»eux'« forceps. 

In certain eases the extraction of the filiroma may lie very 
difficult. We should then use a corkscrew (Fig. 314) which is 
solidly implanted into the tumor, taking care not to enter the 
neighboring ])arts of the pubis, but of forcing it into the |Mirls 
as high as possible, in such a way as to Ije able to easily draw the 
sii|ierior pole <)f the fibroma out of the wound, and to tilt it out 
of the abdomen without running the risk of struggling against 
the op|H>silion of the symphysis. Strong traction on this cork- 
screw suffices to bring the fibroma out of the pelvis at first, and 



INDICATIONS FOB ABDOMINAL HYSTEBECTOMY 



351 



tiie alKlomcn afterward. If it resists all onr cfTorts. we may 
have recourse to morcellement. enucleating from their site one 
or Iwo fibromaloiis masses. Traction fortfjis elose the lips of 
these cavities emptied of their contents and the uterus thus 
reduced in size is extracleil with case. 

For enormous tumors, A. Heverdin's sus|>ension ap{>aratus 
may l>e u.sefui (Kig- 31-5) ; having raised the tumor, it permits of 
manipuhitions round about it and the successive stages of the 
operation l)eing easily carried out. It is useless to use the special 





Fio, 314.— Corkucrow (Doyen). 



Fto. 315. — IteTcrdin'a puUcy. 



forceps devised by this surgeon; it .suffices to hook the suspension 
apparatus to the corkscrew firmly fixed in the fibroma. 

Ilie ligature of the different vascular [lediclcs presents no 
special difficulty. 

Total or Subtotal Hysterectomy.— Should we do total or 
KubtoUtl hy«iereclomyY Richelot has insisted on the removal of 
the organ in its entirety, body and cervix, in onler to entirely 
avoid the secondary cancerous degenerations uhich may occur 




352 



ABDOMINAL HVSTEHECTOMV 



ill the preserve*! cervical »tiimp. It is quite certain that this 
argument has its value, as quite a uumbcr uf such oljserviitious 
have lieen published. It loses much of its importance, if one 
takes care, as we advise, to hoHnw out the cervical stump as far 
as its extremity and of extirpating the whole of the intrace^^■icaI 
mucous meinliratie. It is certain lliat one thus avoids degenera- 
tions of the vaginal face of the cenix; but the total removal of 
the cervix dotw not prevent the development of a secondnrj- 
carcinoma with vaginal cicatrix, as the observations nf Pierre 

, Duval, Temoin, and Hazy and olliers prove. 

I We believe that the hnc of conduct is ilietated by the stale 
of the cerxix. If it contains tibromatous nodules, if there is a 
ausj)ici«n of intrac4*rvical carcinoma, total hysterectomy is the 
course to take. If. on the contrary, the cervix is absolutely 
healthy, we prefer to do the subtotal, \vliich has the advantage of 
being a little simi)ler and more rapid, which is of im|>ortance 
when the o(MTatioii has hislcd h ccrlaiii lime. 

Hysterectomy for Included Fibroids. — If we have to deal with 
an ifichided fibroid in one of the broad ligaments, the operation 
has certain [HM-uliarities. 

The inclusion having been recognized, a matter of ease, as the 
peritoneum which covers over the lunior forms a mobile layer on 
its surface, we commence by cutting the ulero-ovarian pedicle at 
the level of the infundilmlo-pelvic ligament: then two cur^'ed 
incisions arc made in this |}edicle, crossing the anterior and 
posterior faces of the lumor and attaining the body of the uterus. 
We thus fix the limits on the fibroma itself, of a jKritoneiil 
collarette which is separated with care in order to free the fibroma. 
This enuelealitm of the included part should lie done with the 
greatest care and extra care should be taken on arriving at the 
base of the ligament. 

At this level one is exposed to tlic danger of wounding the 
urcttT; this may Ije avoidei] if mte keeps con^tnnUy in immediate 
conltirt with the tnnutr. This method of procedure has also the 
advantage of not ex]>osing llie ogierator to llie risk of laslng him- 
self in bad planes of cleavage and of avoiding wi>unds of the other 
organs in the neighborhood of the tumor, of large vessels or even 
of the |>elvic colon or cecum, when the fibroma, lifting up the 
|>critoncunt unil unfolding (lie mesenteries, comes into the neigh* 




INDICATIONS FOR ABDOMINAL nySTBRECTOMY 



3&3 



I 



)H»ood of tlie large intestine. The inrluded masses lia\'inf^ 
l>een enucleated, the operation is concluded with an ordinary 
hysterectomy. 

Hysterectomy for Gangrenous Fibromata. — Technic is in 
such cases a little special. 

Commence I>y removing as much as possible of the tumor by 
the vagiuu and fill the uterine cavity afterward with imloform 
giiuxe. Then suture the cen'ix. and do a total hysterectomy by 
the ahttomen without incision of tlic uterus, and without nutrcelhi- 
tion. cutting across the vagina between two curved forceps; 
Kronig In fourteen operated cases had thirteen cures. 

Rochard' advises a similar technic; he does a colpo-hysterec- 




tomy and divides the vagina after having attached to it some 
cur\'ed forceps, thus dning the hysterectomy in an isolated space 
as GouUioud has done since IBOti. The important point is to 
avoid all (hschargc of hemorrhagic fluids in the neighbi)rhood of 
the wound. 

Conservative Operations. — Latterly g_vnecologisls liave car- 
ried out conservative u])erations. 

They first preserve*! one or two ovaries, when ihey were 
healthy. It was found sulTicient instead of tjing the utero- 
ovarian artery- at the level itf the iiifumlibulo-jjelvic ligament to lie 
internal to the ovarj-. sin)]>Iy excising the tube with the uterus. 
^ Zweifel goes further.^ lie amputates as high as the tumor 
permits and reesta!)|ishes the cavity of the uterus preserving the 
ovaries at the same time so as to obtain a j)ersistence of menstrua- 

' Kocbftrd. lUmovnl of Ibp L'tvniii in an Isulittcil Arcn in ('«rliun CuMwof Gkngmioua 
nbronuiU. Bull fl Mrm. dr lit .Site. tU Chir.. pAri", lltl'l. p. 'TK. 

* FtvAkcMtviii. Uclicrdii^ Hrdnitungilpr Ktwei'tio L'ten bvi Myonutiur Krliall 
UMuUiution niich der OpcrBtido. Are^./ardjpi.. Berlin. IB07, T. 83, p. 477. 

23 




364 



ABDOUIXAI. HYSTKRErrOMY 



Hon. To prescn'e a sufficient arterial supply for the ovary, wp 
st take varc of thu important Iirani-li it re<'elves from the 



I 
I 



mtisi take oim^ 01 tiie important iirani-n it re<'eives 
uterine artery, and leave a layer of uterine tissue arx>unj it. 
Ilcmove Uie portion of the uterus containing Ihe fihroids. and tie M 
the vessels that bleed: then suture the pedicle in Iwo layers, " 
burjing the first row of sutures under a sero-serous suture, whieh 
at the suine time draws the pedicles of the adnexa in contJiel with 
that which remains of the uterus. 

In more than one-half of (Jie cases menstniation is preserved. 

The conservative operation, par excellence, is myoniectomv' 
which may Ih> carried i>ut in two (lifferent <'on<htions. viz.. for 
|>ediculated myomata or interstitial myomata. 

The removal of pediculuted mtjnnutUi is of the simplest descrip- 
tion. It consists in division of the pedicle, tying vessels if any. 
and suturing with catgut the little uterine wound resulting from 
the intervention. The only difficultli's likely to be met with are 
those of frequent enough a<lhesion.s to omentum and intestine. 
The simjiU'st lliiufj to do is to coimnence by division of the i)e(licle, 
and then attacking the adhesions, tying and resecting the omen- 
tum, freeing the intestine or even leaving some of the tumor tissue 
attached to the intestine if the adhesion is very intimate. 

AMien we have t<» deal with inlerstiiial myomata we incise the 
cortex of the uterus at the level of the myoma and just as far as 
the capsule that surrounds the latter. With a blunt instrument 
such as a pair of curved scissors or a special sj>alula, the tumor 
is liljerated from the cortex thai surroinuls it. If there are 
several myomata close together, they may lie removed by the 
same incision. 

U has Iteen advised in eases of large tumors to make an 
elliptical incision: if one has recourse to tliis incision we must 
take care as Kelly and CuUen advise not to remove too great an 
extent of the uterine cortex as this retracts after the removal of 
the tumor and union may then be difhcnll. It is In-tter to be 
satisfled with the simple incision: free if necessary to resect the 
exuljcrant portion of the ulrrine flaps. 

.\s nnich as possible during enucleation one should avoid Ihc 
opening of the cavity of the uterus and to do so one must be 

■Loubet, Enucleation uriI(oriiioI''ibroi)iaUt>)-Abtl<iTnlnitl Roalv. Tk.dfPttrU. IMI- 
1002, Xo. 3lfi. Kelly wid CiiUvii. Myomfti* ol tlie Utnus. PliiU., 1900. 



4 




INDICATIONS FOR ABDOMINAL HYSTKRECTOMY 



•iob 



careful to n'main in rinse cnnlact with the ttntinr. If l>y niis- 
clmrico it is o|>eiu-(l. ilitate the cervix and leave a drain for 
several days in il.s interior. 




Fio. 317.— TheutvrineiUnue hiubei>iiiii< >-.< .{ ..- turu thi'ttbcllof Ui<!fitifoinB:ii[orcFp« 
dnw> upon t)i« lattrr nnd it in i.ioluli'il wilb riirvcH ■ciMom. 

Oneo tlie enucleation is tinislied, suture the wound in layers 
with some catguts wliieli [miss rif;;)it into tlic .siihstance of the 
uterine tissue, taking oire to get good apposition (jf the purls, in 
such a manner a.n to leave no virtuiil t-avity where fluids may 
collect. 

If there are several niyonias. multiple uterine incisions may be 
m required and procc<'<l if possible from the cavity of Ihc prinri|ral 
B myoma into those of less importance so as to have merely one 
H uterine woimd to KUturc. 

H We catmot yet ap]>reciate the value of these conscr\'ative 

H operations and if we fatv the usually excellent results of hyster- 



INDICATIONS FOR ABDOMIXAL IIYSTEBBCTOMY 



357 



ectomy. we are a liltli- tcrnjiU-d to ix-cede from this position and 
wr fcrtairilv prefer the complete operation which plaecs the 
patient in a position of having to fear no rifuri-ence and no more 
pain from a possihle lesion of the adnexa. Our average mor- 
tality for abdominal operations on fihnmias is 4.1 to 100, i.e., 
1 1 deaths in 268 cases. 



Abdominot Hysterectomy (or Ctncer of the Uterus. 

The first surgeon lo deliberately practice the excision of tlw 
lUcnts for cancer by the abdominal route was Freund on January 
30. 1878. This intervention was rapidly foUowed by a scries of 
others, but its mortality' was so great that Freund's operation 
was abandoned for vaginal hyslort«.'loniy winch was advocated 
by Crcrny in 1880. The immediate results of this operation svcrc 
incontestably belter but the remote more mediocre. 

As the technic of celiotomy became better return to the 
abdominal route became rapid, and as a result the immediate 
prognosis became better aiul perriiillc<I a nmeh more extended 
removal than by the vaginal route. IJy the abdomen it was 
possible to do an e.vlfn.tivv cxrijirioH oj ihv vtmvrr. With this new 
technic are associated the names of Mnckenrodt. Uie.ss, Uumpf. 
Clark, Werder and Wertheim, etc. More and more extensive 
o|>erations were advised, with the purpase of removing ul one 
and the same time the periuterine cellular tissue and the glands 
receiving the efferent lymphatics from the uterus. 'J'he eongn.-ss 
in Kome in 1902 marked the apogee of these attempts. It was 
It Uiis meeting that Jonesco advis4-d prehminarj- ligature of the 
iypogastric arter}' and the "lumbar-ilio-pelvic hollowing out" 
extirpating all the celluhnfalty tissue of the pelvis, iliac fossa;, 
and interior lumbar regions with the vessels and lyniplmtics they 
contain. About Ihe same time Franklin H. Martin in .\merica 
advi.sed the partial excision of iJie bladder witli implantation of 
the urt'ters in the rectum; Samp.son advised the systematic 
excision of the ureters with reimplantation of their upper end 
into a higher point on the bladder wall. 

■ AliUoH in l)CSt ruuiul 73 dniUia in 100 cfMw* doito by Freund : Aumnow found lOtt 
ilulhs In 148 coaCB, 71.6, jarr ICM). 



3SS 



ABUUMI.NAI. HYSTERECTOMY 



These ojieralions are often exct-ssivc and have lo a trertain 
extent been abaiidoiiecl. In particular the systciualic seardi for 
all the invaded glands has been abandoned, as anatonio*patho- 
logical researches sIujw that tins removal was mosl often useless 
or impossible. 

In order to establish it it suffices to recall what researches 
have established in the last few years. We will study from this 
I)oint of view the cancers of the body and tlie cervix .separately, 
because from the points of view of extension to glands tiicre is 
a great distinction between the two. 

In thirty-four cases of cancers of the hodij of the uterus, Kronig 
found only five cases of glandular enlargement; in one case the 
inguinal glaiuls, twi» cases the iliac glands, and two cases Uie 
luml>ar glands. In four of these cases the uterine cancer had 
gone h4'yond the limits of ojicration and in the fifth a cancer of 
the ovary had previously been removed. 

In consequence in all ca.ses of cancer of the uterus which are 
capable of extirpation Ihew* was no glandular enlai^ement. 
The conclusion to draw from Oicie obnermtionjt is tliat it m not 
necesaarij lo search for thv tjlanda in ciincer of the body of tite 
uterus. 

In cancer of the cervix the invasion of the glands is, on the 
conlrar)'. much more important. Schauta in fifty postmortem 
examinations of women, who died from cancer of the cervix, 
found thirly-two cases of infected glands, licing 04 per cent, of 
the cases. The .search for glands seems a priori to be indi- 
cate<l. But if we look for the situation <»f these glands we will 
see that in the greatest number of cases of infected glands we 
find aortic as well as [>elvic glands may l>e in a state of isolated 
enlargement or degenerated. In 13 per cent, of cases only the 
cancerous degeneration is limited to the ])etvic glands, the only 
ones that the surgeon is able to attack and then not always. 

It may be objected that these statistics have been made of 
cases where the [mtients died of their cancer, thus being in a 
different condition to those for whom the operation is a matter 
of discussion. IjcI us then proceed! lo the examination of those 
who succumbed to surgical inter\-ention. Schauta in ten women 
examined found o)dy two with canc-erous glands; Oehlecker 
in seven cases found two. It is true that Kronig in eighteen 



I 
I 



INDICATIONS FOR ABUOMINAL HYSTERECTOMY 



359 



)peralive cases foiitid nine cases of jjlands; but ll must be added 
that Knmij; utlcmptcd the operalion on many cases that by 
others would be regarded as inoperable by ivasoii of Uie obvious 
extension bevonil tlie uterus. 

Kundrat. \vho studied conscientiously the «|Ueslion of glandu- 
lar pn)pagution in Wertheim's cHnic, found in 80 cases 54 with 
gangHonic invasion, about 59 per cent. In 36 cases there were 
infet'led glands Imt thesi? glands were only capable of extirpation 
in 13 per cent, of cases. We therefore find a figure about the 
same as that of Schauta. 

Does this figure of 13 per cent, of glatu/iilar ilegeiieraiionn, 
cajHiblc of being operated on, authorise the systematic removal of 
glands and to expose tlie patients to a research which incontesl- 
ably aggravate the immediate operative j)ri>gnosis ? We do not 
believe it. We are supported in our nonbelief by the results of 
the anatomo-pathological researches of Oehlecker, RosUiom. 
Kromer. Cullen and Sum|>son. who show that the size of the 
tumors, the only factor revealed during a celiotomy, is not a 
certain index of a cancerous degeneration. Large glands may 
be noticed in women and they are merely inflamed, while 
quite small ones may he ilegenerated. If oiu' wishe<l to be sure 
of removing all the infected glands, one shonld remove the whole 
glandular chain, which is of course impossible. 

Is failure the result of tlie abdominal operation ? Not in 
Ihe least. The study of recurrences after old operations shows 
us that the mischief reapjiears at tlie level of the cicatrix in the 
immense majority of cases. Tlus agrees with the facts deter- 
mined by Kiuidrat who. in 160 cases operated by Wertheim, 
found the itaramctrium. invaded in 55 per cent.; with those of 
Brunei who, in 72 j«r cent of maea where the parametrium was 
clinically and macroscopically free, nevertheless found in 72 per 
cent, of Uiesc cases cancerous infiltrations; the researches of 
I*ankow. who, in 60 cases opei'ated by Kroiiig, found the para- 
melrivm affected in 68.2 jjer cent, and finally Sampson in a study 
of Kelly's cases found the parametrium invaded in 20 out of 27 



cases. 



Another interesting anatomo-pathological point, well exposed 



' SttnuMon. .\ Cnrorul Stu<ly of tha PanHnotTiurn in 27 Cu«a of Cnrdnoink Ccrridt 
U(«riudlUCIiiucnlSiKniflcanoe. Jm. Jour. o/ObU., New York. Dot,, 1006. p. 433. 



360 



ABUOMIKAL HVSTEHECTOMY 



by Bnuipt's' examinations on Mackenrodt's eases and by Asserein' 
on Doderlein's. is thai iu a certain number of cases Uiere existii 
ore invasion of tite traginal wall by the cancer, and yet there w no 
change in ihc carTcsiHtnding mucmts membrane. Wo have had 
o<-casion to make the same observations. 

Tlie abdominal uperatum by permitting ilie extensive excision 
of the i^gina and parametrium exhibits even in the absence of a 
glandular extirpation, an ineoniesiablc .vuperitmiy over vaginal 
hyxterectomy and as such merits substitution for the latter. 

Indications.— All cases of caiicer nf tlic uterus do not justify 
an abiloininai operation and one is oblif^ed tu limit oneself to a 
purely palliative line of treatment. In order to present the 
indication of so-called radical ojH'ration, it is necessary to do a 
certain nnmber of exploratory examinations by digital vajp'nal 
e.xaminatii)n. iligitul rectal exHinination, and the cystos(i>|K'. 
\ One should not operate when the vaginal examination shows 
an extensive invasion of the vagina, in |>arti('ular if its anterior 
wall is in contact with the bladder, ur perhaps an infiltnition 
en masse of the broaii ligaments extending to their external 
third. We con6ne ourselves to a palliative treatment when tlie 
rectal examinatiott slio^vs a Iwaded induration in the utero- 
sacral folds or the presence of enlarged presacral glands. The 
cystost^pic exaviiiiatinn of the bladder should always l)e carried 
out. It is evident tliat direct invasion of the bladder should arrest 
the surgeon. The same may be said of certain lesions which, 
according to Hanaes, would indicate the partial invasion of the 
vesical coats. \ prominence of the trigone which could not be 
ex]ilaine<l otherwise than by a mechanical cause (forcing back 
of the bladder by a lat^- Jntravaginal mushroom growth or by n 
strongly anleflexed uterus) or by folds or bullous edema of the 
mucous membrane." According to Clark, the obliteration of 
a ureter would have great diagnostic value, as purely inHanmia- 
tory infiltrations of the broad ligaments never lead to the arrest 
of the passage of urine. 

' Krahniiw.- iter ulnloniinalea RAdikttl«i>«rittl» d«B G«lMnnuUor-Mhciile|tkfvbiM 
■nittela L«|>*r«t<Hni* hyiiuniulncii. ZriritJir./. Gtb.. StuttjtKrI. IWJ&, T. LVI. p. 1. 

* AattnU* (I..), La ]nri>|i>fEDxi>>nc di-l cnrcinoirui Hr) colli) ulvriuo •) tonito pararagl- 
ute. Annttli rfi obifrrrtnn r. giitrailogitt, Hilatio. 1007. 

' A ImlciiiK liki' n IiokcI of Uie ivsolsl mucou* neBkbrene with productinn nf i>M|>il- 
lonutoua iKxIuIn lina u prat imporf n«A (SdiMb) : on the «outrar)r. ft bullous ouenui 
Mwordinit to unpubliithod: rMoarctiM of our iDt«<nio, U wiUioul vslue. 



I 
I 




I.NOICATIUNS FOR ABDOMINAL HYSTEREXTOMV 



36t 



I 
I 



I 



The Operative Treatment. — Is there any preoperative Ireat- 
inenl .- Some gyiiefoiogisls have advised a curettage of tlie 
cancer 8 to 10 days before the hystereetoiuy. 

This practice lias been in the main abandoned. It is well 
lo do a cnrettag*' followed Iiy eauterization before removing tlie 
uterus, but it is done nt the same sitting. 'l*he preliminary 
curettage has, however, its uses In certain cases. 

If a woman is vcr)- anemic as the result of continuous hemor- 
rhages, curette and cauterize her cancer, under anesthesia or 
after a short anesthesia of clhyl-cldoride. This curoltnge fol- 
lowed by tan)]joning with iodoform gauze arrests the hemor- 
rhage and enables ns to lone up the patients in about H days 
or so before the o|)eration of hysterectomy. 

Operation. — Before opening llic abdinen, coinnipnce with a 
careful curettage of the cancer, followed by cauterization. This 
uictho<l has been objected lo on the score that it disseminates 
infectious germs or cancerous cells. We believe that this fear 
is chimerical and we never hesitate to do a preliminary curettage 
and cauterization. 

.\gain in destroying the ulcerated cancerous vegetations, 
habitat of an aerobic and anaerobic bacterial flora, w*c diminish 
the risk of septic contamination during the course of the operation 
and it often hapjuMis that in so doing we have discovered evi- 
dence of other propagation until llien unknown and which con- 
traindicates a iiion> serious intervention. 

If the curettage reveals that a hysterectomy may follow on, 
the rubber gloves are changed and a new operative material is 
produced for the abdominal inlervenlion. The patient is 
placed in the Trendelenburg position and the surgeon makes a 
long incision so as to get a gooil exposure of t!ic diseased |>arts. 
He inserts a large retractor in the pubie angle of the wound and 
some compresses against the intcslines and Iwforc connncncing the 
hysterectomy, he makes with great care an intraabdominal 
examination in order to Rnd out the operative condilitmg of the 
case. 

.-\t this stage he should examine, Krst, the vesico-ulerine fold 
and see if it is invaded by a cancerous nodule; in presence nf such 
nodules, we shouUi take into account Ihe presence 
cicatricial contraction of this fold. The examiuHtioi 



362 



ABDOMINAL HYSTERBCTOIIV 



I 



be cxlendi'd to the broad ligaments ami (.'xU-iisive infillralions 
may 1>e found in the aortic and pivsacral glands. As a i-esidt 
of Lliis examination we. drcidt* wlR'tluT a radical opiTHtion is 
necessary or a palliative intervention. This latter may include 
a hysterectomy and the excision of tlie uterus con.stitiite$ ia 
certain cases the best of palliatives. It is certain that no exten- 
sive extirpations shonUl Ik- made in the cellular tissue, and ia 
order to re<luce the immediate operative risks to a minimum, 
the surgeon should eonKne himself to a simple operation and not 
carry unt the complex manipulations of the cleaning out uf lite 
peU-is. 

If a radiejil ojH'rution is decided upon, do it as follows: The 
uterus, having been seized with care, is drawn upward and a I 
little to oiu' side. .\ll violeucv nuist he avoide<l in taking hold 
of it on account of the friability of the degenerated muscle fiber; 
it is advisable in cancers of the body, lo employ forceps pro- 
vided with teeth which penetrate as far as the neoplasm, and 
after ligature and <livision of the utero-ovarian pedicles, the 
upper |H>rtion of the broad ligament is incised between the middle 
broad ligament fold where the tube lies and the anterior which 
contains the round ligament. This latter is tied at a little distance 
from the uterus and divided: then the preuterine peritoneum is 
incise*! below the vcsi co-uterine fold. Separate the bladder 
from the anterior surface of the cervix, which is generally easy 
and may be done by pressing back the parU with a strip of 
gauze; if there are adhesions cut through them nith small nips 
of a bhnit-pointed scis,sors. When the separator has proceeded 
far enough on tlie vagina, we return to the broad ligaments in 
order lo discover the ureters and lo tic the uterine arteries: gener- 
ally the anterior and posterior folds of the broad ligament, if 
there is no marked infiltration of Ihe parnnietnum. are se|Mirated 
witli ease like llie [wiges of a book. The unHer, in which, by the _ 
way, it isuseless to insert beforehand a catheter, follows, in itsf 
displacement backward the paste ro-intcnial fohl of the 
broad ligament. To expose the 6eld better, split tlie peritoneum 
externally towar«i the iliac fassa, as far as the cecum lo the 
right and the iliac colon tu llic left, pasjiing anteriorly to titc 
utero-ovarian vessels. ■ 

If tliCR- are some enlarged glanils found at Iliis level, se|>arate 



I 

I 
1 




INDICA'nOSS FOR ABDOMINAL HYSTERECTOMY 



303 



them from the outsult* and rcuiove thom with the cellular tissue 
around them in drawing them toward the uterus. 

In se[Niratitig Ihe pitrts of the lateral wall of the |>elvis. the 




Fio. S20. — ^The utenu in ilniwo upwitrd Mid t« Ihi' Ipft. The r«d dotted linv Hhows 
tbc inriiiiun ia the broad liKAnioni. The iitoro-ovariao v«*mIi a-ui round liKumcnt «ri> 
tlod. 



larf^ vessels, the lymphatic and the ureter are elearly exposed. 
Hie ureter follows, as we have already mentioned, the postero- 
internal fohl of the broad ligament, which is held tense by the 
uterus being drawn to the opposite side. The uterine vessels 




Via. !d.— Th« broiul lifi&nicnt hiu lioco >|t1it. The un>t«r may bv neon foUaniii^ i 

di»|)ltioe(l |ii»tor«-int«mttl fold. 



saiiieUmvs from tlie livpof^aKlnc l>y ft C4>mmon trunk with the 
uterine arlery. Then place a pair of Koelier's forceps on Uiis 
vascular [H-tlich- neiirly level with the uterus in such a nmnner 
as to prevent all hemorrhujjic reflux hy the veins, and llien the 





ISDlfATIONS I-OR ABDOMINAL m'STERECTOMY 



365 



uterine veiii.s ami arteries are divided immediately inside the 
B lif^atitre. 
■ Uniting llie pei]i(-te of uterine vessels utth the celluhir li.'istie 

lliat surrourtds them, it is carried toward the meflian line and 




Kio. 322. — Diniion of T4ii' vrnico-ulrrinc jirriiMncuin wlileli I* rollma-eil liy wpamiiuii and 
the [ireMing of ilic lilftdder torvknt. 

Uie ureter Is freed with a hhint in.struineul as far a.s the hIacMer, 
preserving, however, its conjunclival-voscular sheath and as much 
an [HLSsihlc of its (HMitcrinr t-onnections so as to best preserve lb 





Flo. 3'JJ. — Till- ulrdlii- mrU'fJ liu* Invii tiivi niul ilivi.ii-<l. Wilh lin? I'lirvinl 

Uunt xiMTora the unHvr )■ iaokwd and at llx- Mmo Itnw it« own oclluUr ftli«itth ■■ | 
•rvrri. 

below tlic ui-cter. as near ns possil>lo to the wall »f llic cxcnviitton. 
As a riiK- wt' insert several successive sUtcdes and as many liga- 
tures in order to take up the arteries, veins and lyniplmtics that arc 
contained in tlie.se ligiinients. 





Fio. 324. — Tlip UtcriiH Iiax bcrii drawn upwurd And Torwan] ftntl th« pcnloncum pof- 
l«rlor)jr ftDd tlie ubira-HUcml liguneots will next be dividcil alonK tbi' rod <lott«d line. 

utero-sacral Hgaineiils, it is ohserveti that the uterus and vaffina 
mount toward the wound, iiiid this facilitates the cleavage 
K'lwccn Ihc vagina and rertuni. Finally the superior unc-third 





forceps croKs so as to close the whole width of the va|;inu: this 
is Ihen divided with a scatpft Ik-[i>w the forceps in sueh ii iimiiner 
as to remove the cancer in an isolated s|>ace. Bimnii. nhosc 
practice wc have often fotlowe<). dws not iikc curv<>4l forrepSr 




INDICATIONS FOR ABUOMIKAL HYSTERECTOMY 



369 



which to a certain extent hamper the extensive removal of the 
parts. 

He opens the vagina as far away as possible, commencing 
his incision on the least affected side of the tumor and then finally 
attacking the most affected tissues. He makes a sort of pedicle 
of the cancer in order to procure at its site tltc maximum of 
extirpation. 

Pollossun recommends that once the uterus and vagina liave 
been removed with the parametrium and enlarged glands inchided. 
to look for glands which may exist in the pelvic wall about the 
level of the bifurcation of the iliac vessels, extending along the 
length of the common iliac vessels and into the obturator fos-sa. 
They are rect^nizcd by sight and touch. Having located them. 
their dissection should be made with care, without crushing 
them, and endeavoring to remove with them tlic cellular tissue 
in which they are surrounded. 

Having removed them, glance over the operative field, lying 
bleeding points and suture the peritoneum laterally as after an 
ordinary Iiystercel<uny, uniting the retro-vesical to the pre-n-ctal 
peritoneum. As a preliminar}' to this, insert some iodoform 
gauze into the vagina (Fig. 325). 

To produce drainage, Anianu advises incising the [loslerior 
wall of the vagina with a thermocautery as far as the inferior 
limit of the lateral separation. 



I 



Modifications of the Operation. 

Preliminary Freeintf of the VayiHo. — Some .surgeons' have iidviscd com- 
mencing the iipenitioti hv n fr**<'ing of the vagina. After a t-iroumferenliiU 
incUion of the vulvar orificp. thcv di-SNOct up n tiiwou.t iiM'nilirnnouii cuff 
over an extent of ulioitt 4 cm., and they then close thU culT with a purse- 
itring HUture. The rawed surfiiee-s, ri>.siiltiug from tills M.'|>arnlion. are 
Itrouglil logcllier \iy sutures atid the vulva Ls eloscd with the exception of 
n smull space reserved for the introduction of a drain. 

'I'lie perineal stagv of the operation being finished, tlie surgeon goes on 
to the alidominal stage und removes the uterus "en bloc" witb the vagina 
art n cloHed cavity. 

We are enabled thus lo avoid the cnntaminalion of the wouod with the 

' Imbort itml Picrl. Hull. <U In Soe. Hf Chir., 1905. p. 92\ et AnnaU* dtmnloAogU, 
T. \.\\l\, II. «S5; I'. Duval, BM. d* la Sot. lU Chir., June, 1906, Kejwrt by XL. Fau«» 




370 



ABDOMINAL HYSTERECTOMY 



I 



I 



RCptic products of rnnccr at thf* same time lo avoid tltc caatvrous grafts 
during tlic^ operation. In nddition. the priiniiry division of the i-ajJiiDa bjr 
Irnring the uterus Irw (o mount upward, permits us, according to J. I.. 
Faurc, to remove in the abdominal sUigc of tlie oponition hnlh the ut<-ru9 
and Die pcri-ccrvical region almost on a level with the abdominal wound, 
which greatly facilitjiles the delicate dl.tsertion of the ureter and pamnietrium. 
7"rHMjriTr«r InctMon of the tt'all atut Partitioning of the Abdomm. — In cases 
of exten)>ivc cancers. !Ma(!kcnro<lt and Amiiiin advi.>ie making a transverMr 
incision in the abdominal wall and of cutting through the recti and thus give 
a full cxpoMiTC of the pnrt-i. Having opened tlie tilidomen they Mepnnilc 
the peritoneum from the deep aspect of the anterior abdominal wail and 
suture it to the poMterior a.s|>ect of the poueb of Douglas, thu.t shutting otT 
the large peritoneal cavity and isolating by this septum the operative field. 

In order to have a more enduring partition. Kronig take;< the fa»rin 
Irnnsversalis with the periloneum and thus avoids necrosis of the flap and 
the later bunting through of tlie interline into the sup]mrati\-e ujienitivefl 
field, a state of affairs noted in some cases. 

In tb'ia proeiHlure make a curved incision which passed one finger hreadlh 
abov(! the pubis and extends to within (liree finger breadths of the anlero- 
5U|>eriiir sjiine of the ilium on both sides; cut through (he ^kin and aponeunv* 
sis and then the recti about one-half a finger's breadth above the pubis. Tie 
the epigastric vessels which are to he seen on the external surface of the 
peritoneum. 

Drnwing the niii?<culo-cutane<ni?i llap upwanl, we put on tension, the peri- 
toneum forming the floor of the wound and we can ascertain the limits of tl>c 
bladder. We must not draw too strongly so as to separate the bladder from 
the symphysis; if its hmits are not to be seen plainly, we may reeogniM- them 
by palpation. We then open the peritoneum above the bladder. 

Lower the head a little mure at this stage mi that the int(-?ttines fall to- 
ward the diaphragm and suture the peritoneal -trans versa I is fascia llap to the 
peritoneum of the posterior wall of the pelvis. IjeuinninK by ii stitch which 
unites tiie utero-ovarian pedicles tn the llap and then attaching this in front 
of the rectum, fmterally isolate the i>eritoneal cavity by suturing tlir an* 
tenor liji erf the bnmd ligament, previously s|ilil. to the peritoneum of the 
lateral wall of the abdomen. Wc thus gain a splemlid view of our field of 
o|>enilion, and at tlie same time an nccluaiun of the peritoneal cavity which 
prevents any irruption of the intestine. The uterus, upper part of the 
vagina, ami the paratnetrinm are ei^ctirpated in the usual manner. 

Mackenrodt recommends detachin); the parametrium from the pelvic 
walliiiordertoreniovtMt initMcntin^ly with juxta-rectaland pre sacral glands. 
We then srv the glands along the length <if the iliac and obturator vesseU 
which an^ r^'moved secondarily, l-lnally insert a vaginal wick. The uterus 



i 




iXniCATIO.VS FOR ABDOMINAL HYSTCKBCTOMV 



371 



m^st not be in cnnljict witli the f^nuzv, to tliU ciul, liury it by suturing the 
lateral portion of the extremity of the vagina either to the Madder or to the 
vejiical ]writniieHKi. ('lost- the opKrHlive field above by uniting the vesical 
pcritoQeum to the rectal peritoneum and carrying Uie aulures iii fur liiterAlly 
m* the utero-ovnriaii iiediden. 

On the fifth day remove the gauze nick ami make the (uitient ^it up in 
onler tlint the intniali(Ii>niiniil pre^t^ure may diminish lu much as possible the 
existing cavity. 

Complications. — The most iin|M)rtHrit rrtni]>Iirjition Is either 
infertion of the pvriinncum, or of iheccUiiUir tUsiw, ami acconiitig 
to Bumm' in eases of cancer, infection extends much further 
tlian the litmor. even to the extent that the tissues in the ncigh- 
lM)rho(Ki of the litems are almost constantly found to contain 
streptococci. In operating on these infected tissues, that infection 
of the peritoneum anrj the wound should take place is not to he 
wondered at. Patients who had fever hefore their operation 
are particularly <langeroiis suhjects. 

Curettajfe followwi hy tln-nno-cauterizjition is insufficient as 
the thermo-caulerv hardly extends its action 1 cm. deep. 

In order to have a more r(Hii])Iete disinfection. Mackenrodt. 
after a curettage carried out on the day Ix-fore the openition. 
tam|M>ns the vajjina and the <'ancerous cavity with a lonj; strip 
of gauze steeped in a solution of 10 per cent. c<)mmercial formol, 
which is then gently expressed. The vulva, the amis and in- 
ternal surface of the thighs are gi-eased with va.seline so as to 
avoid the irritating action of any drops which mav overflow, and 
Bumm tries also antistre])tococcal vaccination but. up to now, 
has obtained no results. 

Fresli research aj>i>ears essential to us in order to establish 
the cause of postoperative infections which are fre<|uent enough 
after alxiominal hysterectomy. We think, however, that it is 
useless to always call into <|iicstlon the preliminai-j' Infection of 
the cellular tissue of the broad ligaments and hold that the 
length of the operation an<l the contusive manipulations suffice 
to explain certain cases of a-Ilulitis or peritonitis. 

The same reasons cau.se sfioc/c to be dreaded parttculuHy 
in fat patients with cardio-pulmonar)' affections. 

' Bumm. Zur Wclmik dcr ubdotninAlen Estlrtintion do KAriin<inin(£tM>n t'wnia. 
Zo(»r*,/ur Gti>- uad Gyn,. St.uttiwn. IflOS. T. LV. p, ITS. 



r- Hrr.t^ TTSTEHECTOMY 

■ -^—.HiiL I 3Kcdoa and shock, the other most 
-ijicL-as^utct ,^r tiuse connected with the urinary 

. T ■•.a -ccfirni* is not exceptional and may lead 



-- ^^'irat imi i>iight to be treated by catheteri- 

— ■^■'■t. li. * "ill* bladder. The traujtiatic lesions of 

1- - -*Am.t*i iuring its separation ; late necrosis is 

: - : ■ *fiii»-THia with a too extensive denudation 

.....r-- ■_'* -iS Txasufii-lent re-clothing of it. 

^. c_ Uu-itannit the principal cause of this late 

- M.-«nL'aunn ic the bladder in the peri-cancerous 

■'■^v** 3e iiivises in case of adhesions to freely 

jLwatt- f^verrntc the mucous membrane if possible 

:„,M . I* tr-^tf^ are much more important: this 

- i-«ii*iB*i mnns the operation ; it has been wounded 

. v.^!' -1 » ifjuAZ^ series of 200 cases by Wertheim; 

j^ ■__ , ^c*.'iint wrws equally of 200 cases. Secondary 

licwc**. *» urnary &tula. coming on about the seveii- 
. ^^..cMtia la ■ i*s been observed in 24 out of 400 cases 

:« -(awsueov-v *.^ too extensive denudation of the 
V ■ ^j^i^ ilis s wfci:raphic wire in the field or perhaps 
».^.» >» :i*r ,-a»,vr in the neighborhood of the cervix 
^ ■ .i:->r*i -iw- -t* wall has lost its resistance. 

, -.nc ~Tg^ JurinjT the course of the operation, we 

.*t :»<■ xTrtW fn.>ni sight nor pinch it up, nor draw 

... --otl^ t*."* tois«.>late it from its surrounding cellular 

. ■ v=-^ OA*!*. it is necessary to do a uretero-cysto- 

, ^ ■»«. ^ ■rtA.'WB J*r I'lvirrpn naph Apt erweiterten abdominalen 

" ,«.^-« B."**-- -«-*■■*■ f- t^**- '""^ ''>" ■ Stuttgart. 1908,T. lAII. j.. 

^.\w is. i«*<«-w;-.a1»rily twplwtimcR in order to increase the ojMTtt- 

^ .i\* •«■> vr i«*r of «voml npcnisis. 

"" ..^. ■s-:.\;n* ;■** i*miinal p»rl i>f the uri-ter in the thicknpss nf Iho 

■^ -1 ■*. *■"■ WiJsTW whioh I«kf lip till' must <lc|>cn(lent portion of the 

^ '■«».■««<' »»'i unit* ii to the \Tsipftl i-writoncutn ; he maintains the 

... s. !»:«»; «T»llof th* [vlvist'v iiiiiiine tlie iiedicle of the uterine 

'.' J ^..■. ,.v-'iti «fr.Kh i* virswii a lillle iliiwiiwiini. The uretct in thus 

""^^^ ^, K-r-viwi. " «>n a fork fumiiHi l.y the utrrinc artery and the 

_^^ ,,, ,'^ • i^»r%l«rt'lie«it to the UtefHl wHllof thei»clviB (Aniann. 

•»!v '..fit ^ «i:«¥ioi.'hnter Heekenuusraitmung wefcen Uterus 

" ,^ ' .. ■ . « .-..' - ^^tutt^art. liHi:. T. I.XI. p. 2). 



INDICATIONS FOH ABDOMINAL HYSTliRECTuMV 



373 



lomy iiuniwiiatcly; on the coiilnir\'. however, mi fistula.s 
foflowing on necrosis of the canal, there is no need to be in hurry 
to tii) uii intervention. ThoM- listnlas heal Kpontaiicoii.sly in TO 
per cent, of coses, from two weeks to four montlis after the 
operation and with conservation of the |M'riiicahiUty of the ureter. 
We shouUl not hasten to a too early nephrectomy until thei-e are 
marked signs of ascending infection; the uretero-cysto-neostoiny 
should he done in persistent fistula, when the corre^jmnding 
kidney is healthy or even when dise«se<l unless a disease of the 
opposite kidney contrHin<lic»te!! nephreetoiny. 

Results. — Abdominal hysterectomy with resection of the 
vagina and parametrium should be cunsiilered from a triple 
point of new; 1. Operability; 4. Immediate results; 3. Remote 
results. 

1. Operability. —The abdominal operation, such as has been 
done for the last ten years, has enabled us to extend the do- 
main of radical operations. 

PoUosson managed to operate .^6 per cent, of cancers that 
came to hospital; Wertheim. 00 per cent, to 65 per cent.; Doder- 
lein, 09 per cent.; Itunini, SO per cent.; Kronig, 87 per cent. 

That is to say, a great number of surgeons do not hesitate 
to have recourse to a radical operation in those cases which would 
certainlv never have been done before. 

2. Immediate Itesults.- -In spite of the great extension of the 
operation, the mortality is hardly mure elevated than it was for- 
merly in the days of vaginal hysterectomy. Leaving on one side 
canrerx of the Inxti/, the mortality from which is almost nil, and 
considering only the cancers o/ the ccrvij; we arrive at the 
following results. 

Mackenrodt' in 09 cases had 16 deaths=20 per cent. In 
reality, the mortality is much less, because at the eommenee- 
ment Mackenro<lt reserve<l the abdominal operation to cases 
which were unable to be extirpated by the vagina. Since he 
o)H'nite<t all cancers by the abthunen his mortality fell to abmit 
1 1 per cent. 

Doderlein," 47 cases, 7 deaths = 14.8 [)er cent. 

' Mnaki-iirudt, Erei-lmiiuic dcr nbilominiilen Radi](Mlot>onilion dcr npbiirmuttar- 
•chriiii-nkrcl-jes millrtit l.itpnriitoniiu hyiiogavtricft. Z«it»thr. /«r Grb. und O" 
Stuttfori. T. I.IV. t>. ol4. 

' Doderleiu nnd Krotiig, Opemtivc (lynAkoto^e, Second Edition, tioipm^, IV 



374 



ABDOMINAL HYSTEREtTOMV 



Bumm/ 82 caws. 17 deatlis=S^ ppr t-ent. ^^H 

Pollosson.' 133 cases. 17 deaths = H i>cr eenl. 

Sclu-il),* 14!) cases, 30 <lraths = 20.l |ht cent. 

Franque.* 51 cases, 8 deaths = l5.7 ]jcr cent. 

Scliimiler,' 117 cases, 10 <lealhs=13.67 percent. 

Worthcim," first series of 400 cases. 40 (lcatlis='24.5 per cent. 

Laterseriesof ^OOcases, iOde!ilhs=10 per cent. 

As tlie second scries uf Wertlicim's witrk apjiears we see how 
tile mortality tends to diminish. It is the same wltJi PoUosson's 
cases; while Ihe first seric's gave a mortafity of 18..1 [ler cent, the 
third series gave only 8.5 per cent, and the 36 last jmtients ope- 
rated are all cured. 

This amelioration in the immediate results is general. If 
only recent cases were cited we should, as Scheib says, find that 
Werthc'iin has a mortality of only 7. .5 per cent, and Hoderlcin. 
5 per cent., figures wliich agree with those of Koblaiik, who had 
5.4 per ct-iit. of deaths according to hi.t late.st report. 

In fad there is a diminution in the mortality in the ahdom- 
innl o|H-riilinn identical with thai which occurred in the vaginal 
oj>eraliou when the mortality fell from iO per cent, lo 4-8 
per cent. 

3. Remote Results.^For cancers of Ike botty of the uterus 
remote result.^ are excellent; in 13 cases of cancers o]>erntwl hy 
Dodcrlcin, two tiled of intercurrent disca-scs, two died of meta- 
stasis in existence before the operation, eight are without any 
recurrence after more than tlirei! and one-half years have fled. 
According to Scheib 75 per cent, of cancers of the body of the 
uterus are definitely cnriNl.' 

For catu;ers of the cervix the remote results are very sujicrior 
lo those formerly the case in vaginal hysteriTtomy; above all when 
it is considered that cancers regarded as inoperable at Ihe time 

' Bunim, Zur Tcotinik dor iihdoiiiiiialon Hx^tirpntioii d<rr k«rilDom*tOMi) t't«ru«. 
ZeUnekr.fUT llrb. unrf Gyn., Stmigtirl, ISIM. T. LV, p. 173. 

' Pollooon, Jlyatnrcotomv n-ith Hollowing Out of Ibc I'olvin. /.von cKirura., 190(1, 
T.I, p. 333. 

'scbHb, Klin UIlll.^tlat Bcilr. i. upiTutiv. Itehandl. tint L'T«ruiicftTOiioit). Artk- 
JUrCm., Hcrliii, IIKHJ, T. I.XXXVII, |i|>. 1-2M3. 

'Franqui' (Ulto v.), Zur Slatixiik tli-r 'luerativi-n Heliftnd. Iwi t.'(CTUiih»r(litoiii«. 
Mon.JtkT Orb. und <iyn.. Berlin. 1909, T. XX.\. ji. 20. 

' Schindlrr. iflBtiat. und Biiat. KriccbniKv hri dir rrcuii(l-Wfrrt|ipirotoh«B R«dikftt- 
)>per*lion d«r L'teruakiiraiQain. Mortal, fur Cfb. und Gin., R«rhii, IM6, p. Ttl. 

• Werthfini, Sot tnttrniH. de thir., BnixcllL-ii, lOOS, T. I, p. h*\. 

'&«hrtl>, KlimK-li« und Ktiutoini»cii<-. Boitrneo tiir Dijcniti von BehnndlunadM lit«ru»- 
ItATliDOina. .\Tfhiv fur Gyn., Itorllti, \W9. T. I.XXXVII. i>|>. 1 mid 1'33. 



1NDICAT10X8 FOR ABDOSUNAL HYSTERECTOMY 



375 



when only the vaginal route was praclised, an- retiioved by the 
abdomen. Bumm in 40 cases noles J7 recurrences, 6 patients 
were lost to view and "iS, of whom iO had been ilone over two 
years l)eforc, gave a result of 57 per cent. 

Wertheiin in 151 cases after operation had four deaths from 
inlcn-urrent disease, 59 recurn-nces and 88 cures found after 
five years' interval. givin<j 59 per cent, of lasting cure. 

Maokenrodt in 144 eases fouiKl 74 per cent, of the patients 
living after a variable period of eighteen months to six and one- 
half yearn after operation. 

Scheib in the clinic at Prague finds 63.5 per cent, of his cases 
living after two years, after three years 58.8, after five years 
58.5. and after si.v years 27.2. 

I'ollosson, in 1909, found 35 per cent, of eases operated before 
Junc,l905, quite well; 61 per cent, were operate*! in 1965 and 
1906; 69 per cent, were operated in 1907. 

It is still diflienlt to come to a deSnitc eonelusion uith n^gard 
to the radical cure of uterine cancers, as operations are not 
always made in identical conditions. It appears aceonJing to 
resulLs published that certain gynecologists, Bumm. Mackenrodt 
and Kronig for example, intervene in cancers with extensive 
invasions and that they do a very extensive extirpation, search- 
ing for glands and carrying oiil their excavation as far as the 
levator and this explains the considerably higher early mortality 
in their results. Others, and particularly French surgeons, are 
not favorably disposed to llie radical o])eration in eases of eanwr 
which have manifestly spread beyond the uterus. These differ- 
ences in the extension granted to the operability of cases and in 
the extent of the incisions explains the ditference-s found in the 
statistics. 

However, it is established to-day that the abdominal operation 
IS superior to vaginal liyslent'tomy from the point of view of 
early and remote results. 



Hysterectomy for Prolapse. 

Abdominal hysterectomy is only exceptionally jjraetised in 
esses of uterine prolapse. 

Its-technic presents no iieculiarity with the exeeptior 



376 



ABIMIMIXAI, HYSTEnECTOMY 



fixing firmly the slump of the ccn'ix or tho dome of llic vap'na 
cilhtT to till' apoiK'urosis or to the muscles' or to the pedicles 
of the broad ligaments (Ligamejitary Trachelopexy, Jacobs). f 

llie technic of nlnlominal hysterectomy m puerperal infection 
has no peculiarity. Here total hyslereettmiy is absolutely iiulj- 
catetl. The minute protection of the peritoneal cavity will be 
tlie principal care of the o[)crator on account of the extreme 
virulence of the uterine contents. It will be found of advantage 
as in hysterectomy for epithelioma of the uterine cavity to 
close the cervix by some sutures before commencing the ex- 
cision of the uterus. 

Abdominal hysterectomy for puerperal infection gives a high 
mortality. 6 deaths in 12 cases (Mnuchutte).' 



1 



Hysterectomy In Uterine Ruptures. 

Hysterectomy is indicated in complete ruptures of the uterus. 
In 28 non-o|)eralctl rupture-s Pinard olwerved 20 dcath.-i, in 
nine operated cases, five deaths only: it may also be added that 
in two of these last cases the operation was done "in extremis."* 

The operative technic should, we think, vary according to the 
leat of rupture either in front or lM*hind the vascular uterine 
pedicle. 

If the rupture is situated behind the uterine pedicle, hysterec- 
tomy is dime as usual, that is, the uterus is divided at the level of 
the most inferior part of the tear. 

If the rupture lies in front of the uterine pedicle, as is jrenerally 
the ntsv in extensive lesions of the cellular tissue, a rather irregular 
supruvHginal hysterectomy is done, dividing, as in the prece<ling 
cum; the uterus at the level of the inferior part of the rupture, 
but Icrmiuating by fixing the .suture<l uterine pedicle to the deep 
KUrfatv of the abdominal wall, marsupializiiig and draining the 
seat of contusion of the broad ligament. If there are symptoms 



' A. Pallowon, ToUl Aliiloniinnl Hystrreotomjr with Colpoprxj: in Uie Trcadneot of 

pMI 
iBfootlan Pn««nfi.>ftioo. Th dr Pant. 1902-1903, p. 412. 



OBrUla l*rolBpM)i. 
' Moudioti 



HuU. rfi I<j .Sor. dt'rhir. dr Lyon. Anril, llinis, T. ]X, p. 137. 
DoQiiincnU In Hi-lp IffwurJ tlie Sluriy of HjBtwi-ctoiiiy in PuMiwnU 



'SkUvaiEc. rnllioloEicnl Annluinv luid Treat inciit of I'lcrinr Riiptunw Ditrinjc I.at>or. 
Tk. lU I'ant. a Stniilicil, 19(11 |\H]2, No 305. Tti* SlAlinii'8 i>f Ihv Munirh (tinio 
■bow tlir ii<i|K'hi>rl1y of inlcrvpntion. All tirin-uii<irKl<T<I vuaea died, while tlir opl^nltion 
MVOi< til iM'r «rht. (V. Wi-I.wr. IHu kompl»tt<-n I'trniiiniplurtTii dct Iclitvn &0 Jkliro Mt 
den M.meliner I'muenkUiuk. OtiJr. i. 6'«i. urtd Gir*-. lOW. T. XV, p. 53.) 




INDICATIONS FOR ABDOMINAL HYSTERECTOMY 377 

of infection or if the tear extends to the vagina it is of advantage, 
as Dragiescu and Cristeanu advise, to do a total hysterectomy 
with vaginal drainage.' 

' Dragiescu and Cristeanu, On the Treatment of Ruptures of the Uterus, ^ilnn, da 
Gjfn., Paris, Feb., 1902. 



CHAPTER IV. 

OPERATIONS ON THE TUBES AND OVARIES. 

Sommuy. — Removal of tltc ndnexn (health}-. inflRini-*], ncopla^mic) : 
cotLtervativc oi>erations on th<* tube and ovmry. 

I. Removal of the Adnexa. 

The tt'*'liiii(' of tlie operation varifs atTordirig as wc have 
lo (leal with healthy adnexa. diseased adnexa either from inflani- 
matorj- or neojilasinic lesions. 

I Healthy Adnexa. 

The removal of healthy adnexa is one of the simplest of 
operations. 

Operation. — ^A small vertical incision or better still a crucial 
incision of tht- wall will suffice. 

The ahdonien having been oiiencd, the intestine pressed 
back, thanks to the Trendelenburg position, and protected by 
compresses, one proceeds to look for the tul>e and ovary. The 
hand being introduced liehind the broad ligament finds thv 
adnexa with ca.se ami dniw.s thcui up to the wound. Then 
divide the utero*ovarian pedicle at the level of the infundibulo- 
pelvic ligament. Cut acrass the lul»e right up against the uterus 
without a preliminary ligature; having done lliis. put a ligature 
around the uterine artery at the level of the angle of the uterus 
am) cut it* external to the Ugatui-e. Then detach the adnexa 
from the sugierior border of the broad ligament witliout the 
least bli^-ding. 

The iinimrlanl point is to remove the ovarj' in toto, cutting 
through the liganii-nt at some distance in .such a manner as to 
avoid a frequently committed fault which is to leave a sort of 
tail on the orgnti at this level. 

|,, ilenioslasis is very easily realized by isolated ligature of the 
vessels; nothing remains but to unite the two lips of the broad 

37S 




REMOVAL OP THE ADNEXA 

lent, burying the ligntim-s of tlio urlcriitl pedicles and the 
uterine inserlitm of llie tube. 

This method of removal is as ra\nd as the loo lengthy clasitical 
procedure which con-sists in lukinjf up with two large inter- 
locked ligatures all the upp?r pnrl of the broad ligament. Il lias 




Fio. 33A>— l' 111 lull' riLl rcniovnl of ()ir^ mlncxa. Two ligutures are uppliMl, <mt clo*c 
aitklnsl the uttniii on Ihc trrniinftlion of Ilic uti-rinp nftcry, (he nfJit-r i-itcmnl to the 
ut«ro-ov«riaii vcNHf l«. 



the advantage of Klling the three (lesiderata that we have already 
on several occasions formulattn], doing away witli large pe^lioles, 
isolated ligature of vessels, and reconstitution of the pelvic 
|terit»neun). 

Indications.— The removal of heallliy adnexa bas| 
udvincd in a ivrtaiti number nf east's. On the advice of 1 



CHAPTER IV. 

OPERATIONS on THE TUBES AND OVARlES." 

Summary.— Bcniovul of the odnexn (Im^aUIiv. iitflumcd, Hoo|)la.%mic); 
coQBvrvalivo uperntion.s i>n llic tube and oraiy. 



1. Removal of the Adneza. 

The li'chnie of the operation varies nceoitliiig as we have 
lo deal with healthy adncxa, diseased adnexa either from inflam- 
matory or ripoplasiiiic lesions. 

I. Healthy Adnezt. 

The removal of heallliy adnejja is one of the simplest of 
o[>eratloi).s. 

Operation.— A small vertical incision or I>etter still a crucial 
incision of the wall will suffice. 

The abdomcu having been opened, the intestine pressed 
back, thanks to the Trendelenburg pasllion. and jirolectwl by 
compi-cxftcs, one proccwls to look fur the tube and ovary. The 
band being introduced behind llie broad ligament finds the 
adncxa with case and draws theni up lo the wound. Then 
divide the utero-ovarian pedicle at the level of the infundibulo- 
pelvic ligament. Cut a<-ross the tul>p right up against the uterus 
witliout a pi-eliminary ligature; having done this, put a ligature 
around the uterine arterj' at the level of I he angle of tlic uterus 
and cut it •externa! to the ligatuj-e. Then delaeh the adnexa 
from the superior border of the broad ligament without the 
least bli*e<ling. 

The important point is to remove the ovary in toto. cutting 
through the ligauieiit at some flistunce in such a manner as to 
avoid a frequently committed fault which is to leave a .sort of 
tail on the organ at this level. 

1 1 , Hemoslasis is very easily realized by Isolated ligature of the 
vessels; nothing remains but to unite the two li)>s of the broad 

378 



RKMOVAL OF THE ADNEXA 



» 



liguDiont, buryinjj the lijfalures of the arterial pedicles and the 
uterine iDsertioii of tlie lube. 

This luetliod of reniovat is as rapid as the too lengthy classical 
procedure which consists in Ijiking up with two large inter- 
locked ligatures all the upper part nf the broad lijpiiucnt. It has 




fia. an. — rnilntcrftl rciniovitl u[ Itic »iliii'xa. Tuu 1i)^tiirc^8 are i>|>pUed, one olOM 
agninst (lie ulcriif' km iUv tt mix nut inn of llir ulrriiiL' nrtrry. the nlli«r fxtcrnnl to tiM 
UlCTO-oviman vcui'ln, 

the advantage uf (illiiig the Ihrc*- desiderata thai we have already 
on several occasions formulated, doing away willi large jH.'dicles, 
isolated ligature of vessels, and reconslitution of Ihe jwlvic 
peritoneum. 

Indications. --'i'lie removal of healthy adnexa has been 
advised in a certain riunilicr uf cases. On the advice of Bailey, 




380 



OPEKATIONS OX Till!: TUBES AND OVARIES 



it was done formerly for nervous troubles (hysteria, insanity^ 
epilepsy, niaiiiu. nu'liinclioly. nyniphomnnia. elc). It j?ave net 
satisfactory n-sult. The oiily case wliere il was authorized to y>e 
done, and still is, is that comtilion wliere nervous troubles are- 
in relation to menstruation and nhere after faihire of medieinal 
thera]>eulies. Ihey are sufficient to make life niiserahh'. 




Fia. 337. — UnilBli'r&l ramuvul iif iIk' uIiu-km. A nttcut i:ifiiliituiiu> nutim unitM* 
Ltyrm of (liv broiul ligAninil, liurjiiiK l'"^ vunnilnr ligaturra, 

Ilegar proposed it as n fMilliatiiv ireittment of uterine ^braids. 
To-<hty with a sinipIiKed teeliriic of liyslerecloniy, il lias been 
abandoned for o]>erations wliich attack the fibroids directly. 

Oophorectomy is still practise<l in (ti/xnienorrh^a railed 
ovarian and altributed to a iliflicuU ovulation. Tlie exami- 
nation of o%'aries removed reveals no lesion; It appears lliat one 
is confronted by a sini]>Ic neurosis and which Ininlty ever caltti 
for operation. 




HEMOVAL OF THE ADXEXA 



381 



Prulapsc of ovaries, which frr<|i»'iiUy acconifmnies radiatinf^ 
pains, and pains in coitus and defecation, etc., has been regarded 
as an indiealion for ooph*)!^^'!^!)}-; to-(Ja_v we prefer ovariopexy. 

Fchiinff advised the removal of the ovaries in osteomalacia, 
Beatson in inoperablr rmirrr of tlu- Irrcnat. It is certain that 
amelioration was olitained in (Mtconialacia, but in inoperable 
tumors of the breast the results announced had been contested. 

Finally, some accouelieurs have pnu-tised it when a narrowing 
of the pelvis necessitated a Cesarean section in order to prevent 
another pregnancy. It is more logical to remove only the tubes 
or to simply remove a segment between the two bpatures. The 
patient cannot conceit again while she pn-servcs the internal 
secretion of the ovarv and a normal menstruation. 



11. loflammttions of the Adnexc. 

Operation. — When the adnexa sliow inflammatory lesions the 
course of the operation procceils as in thai for healthy adnexa. 
But in the former we have superadded a special condition, 
which comprises the most delicate part of the operation — tlie 
freeing of the adhesions. In studying abdominal hysterectomy 
we have insisted on the ditferent characters of the adhesions 
and oti the manner of detaching them and the treatment of the 
complications following on their lil>eration. We will not return 
to this suliject. 

Indications. — The bilateral removal of the adnexa has been 
considered for s<»mc time as the treatment of choice in inflam- 
mation of the adnexa. To-tlay it is the rule to always do a 
hysterectomy at the same time. To ])reserve the uterus when 
the adnexa from both sides have been removed is, to us, ridiculous. 

If one wishes to do a conservative o|>en»tion it is above 
all the ovary that one shouhl keep. The uterus, after removal 
of the adnexa, has no purpose. Generally inflamed, it con- 
stitutes a us4'Icss heavy organ, which is the origin of pain and 
various discharges. Its removal, far from cumpliealing the 
operation, simpliHes the o|>eralivc procedures by doing away 
with the cul-<Ie-sae of the [lelvis, in making its cavity smooth 
and in assuming a better drainage, where this is wanted. 





382 



OPERATIONS OX THK TVBES AND OVAHIES 




The limited miioval of the adiiexa lias only one indication,' 
that of irreparable lesions on one side and a {lo&sihic conscr\'a- 
tistn of the uterus and adnexa on the other side. 



III. ITeoptasms of the Adnexa. 



Tlie neo]>IasiiLs of the adnexa an' so various that il is inipossi- 
hle to describe an o])erative technic for their removal which even 
in its broadest lines wouUI be applicaltle to all eases. 

Operation. From the jioint of view of operation, neoplasms 
may be divided into two ((roups: 1. Small, solid, or fluid neo> 
plasms; 3. hirfri' cyst^ (ovarian or parovarian). 

1. Extirpation of snuill ucnplanm-x (papillomas, sareomas, 
carcinotnas of the IuIk-s. S4>lid tumors of the ovary, etc.) res«'mbles 
greatly the operation em|)loyed for removal of healthy or inflame<l 
adnexa. The abdominal incision should lie long enough to 
permit of an easy execution of intniabdoininal manipidations. 

Soft tumors and papillomas bleed when ihey are dn»«-n 
externally. It is useless to anx'st the hemorrhage in tlicir friable 
tissues and it is necessarj* to search for their vascular trunks as 
rapi<lly as ptxssihle along the length of the [H'tvis and near the 
uterus and then to clamp and tie them. When the hemorrhage 
is menacing we are foreed to n'nmve as soon as possible the mass 
of the tumor. Stop the hemorrhage an<l imme<liately do a 
minute toilet of the pelvis in or<ler to find ami remove, if 
nccessaPr', the abdominal pieces of the neoplasm. 

As in inflammatory' lesions the concomitant removal of the 
uterus is necessary in bilateral lesions. 

2. ITie removal of large ojatic tumors present.s a certain 
number of jM-culiarilies. 

In the usual form of the ovarian cyst, the question of 
pn'liminary puncture presents itself. It is not so much a 
question of puncture as means of diagnosis, and justly an expio 
atory celiotomy is to l>e preferred a.s iK'iiig less blind and le.* 
dangerous. It is no longer a question of puncture as a thera- 
peutic agent; it is only done in patients whose condition is al- 
most desi>aired of tir where looadvaTiee<l age eontraindicates any 
serious intervention. We allude to the enormous ovarian cvsis, 
with respiratory (rouble, edemaloiis iiilillration of Uie wall, eases 



a 

I 



RICMOVAL OF THE ADSEXA 



383 



in which the abdominal tension is such thai when the tumor is 
reniove«l, more or less grave troubles are apt to sujjen'ene. 

In these eases, preliminary punelurc may render scr\'iec. If 
carried out two or three days before the operation, it presents no 
inconvenience and prepares the piilient to withstanil the removal 
of the enormous mass wliich .she is accustonied to. 

Tlie operation is conducted in the following manner: The 
table on which the patient lies is almost horizontal and the 
first stage.s of the o|>eration arc done in this position. Whatever 
be the volume of tlie cyst, eomuience by making an incision of 
me<)ium length, and the evacuation of the intracystic fluid 
permits most often of reducing the tumor l»y a large proportion. 
The peritoneum should be opened with caution in order to 
avoid the woumling of the venous sinuses which Iwi.st :il>out in 
tlie substance of the cystic wal! and, above all. do not prema- 
turely open the pocket. This opening would have as a con- 
sequence the elTusion of tlie cystic contents into the abdominal 
cavity; and although the contents are generally aseptic. Its effusion 
into the peritoneum would helj> tlie conflagration of infectious 
complications: moreover, it helps to graft epithelial elements and 
the development of secondary tumors.' It should thus be 
avoided. 




I'm. 338. — TrOMr for ovariut oyaU. 



Tlic abdomen having been opened, the operative field is 
limited with aseptic compresses, which are insiniialed between 
the cyst and the wall and which completely tampon the j)ori- 
loneal c«\'ity and cover over the lips of the ahdomina] incision. 
Puncture the cystic ma.ss at a point where there arc no large 
vessels and with a stout trocar, to which is attached a rubber 
lube and an aspirator, or else the extremity of the lube rests in a 




H*rtinnnD and I^oAon. Xcoplflnmic Hrnftii Ann. deOym., Pftrii. 1007, p. 65l 




384 



OPERATIONS ON THE TUBES AND OVARIES 



vessel alon^ide the operator. As soon as the cyst common 

to empty. Uie ussUtutit increaM.'s the pressure slowly on tlic abilom- ^ 

inal wall with his hands. f 

Continue until the wall follows the retreat of the cystic pouch. 
Wu'ii this latter becomes foUied. the ojierator seizes it with 
fon,"eps so as to dniw it gently cxlenuilly. Do not draw roughly 
on the forcvps as the cystic wall often is very friable. If the 
cyst is unilocular, as is the case in parovarian cysts, the sac 
entities it^-lf completely and may with gtv&t facility Ik? drawn 
outM«Ie thn>ugh a very little incision in the wall. If there are 
several ItH-uli. empty the larfjcst hy i>erforaUng them with the 
trocar (Munt which is left in the primary puncture point, and 
coiisei'utivvly perfomtes the walls of the various loculi. 

Ihwv the volume of the cyst is sufficiently rciluced. draw 
tMit thtf trvH-ar and ohliterale the orifice of the fracture with the 
aid v»f a s|»eci«l forceps called cyst forceps and draw tlic cyst 
with tht' semi-st^tlid portion it contains out of the abdomen. 
\t this sta^*' elevate the pelvis, isoluliiij; the intestine carefully 
\«ilh c^mi|»n''sses and then we treat the pedicle. 



I 
I 




Fin. 329.— Cyst forarp*. 



'I1»e leiijilli and thickness of the pedicle van,' greatly. 
I'XtlliH^I bv the >u[K'rior |>art of the slrelchcd l)roa<l ligament, it 
\ii»iil«iii^ the uterine and utero-ovarian vessels which arc apt to 
^ uuiutetl in a single group as in the removal of healthy or 
^l^tm^l iidiicxa. one is forced to tic tlie intenml vascular pellicle 
UmI iW evlvrual vawular pedicle separately without interlockinj; 
^. twn h|;«tur\'s. The central purl intermediate l>etwcen the 
i^, .e* does not generally bleed, and if a vessel has escaped fl 

UM> |VkV iMUici)Wil li)(alurcs. nothing is simpler than to enclose 
Ut Uj. Wi vMnt ti^ture; conclude by uniting with a continuous 



I 




RF.HOVAl, OF THE ADNEXA 



SS5 



sulure the two folds of the broad ligament at the level of the 
space intcrinedinte hetween the two vascular pedicles, which 
one is careful to bury under the Hne of sutures. 

Operative Complications. — ^Tlie operation presents sometimes 
a certain number of difficulties. 

Ailhesioiis. — Exicnitive parietal adhesions may lead to two 
compliealioiis when the incision is made in Uie wall, depending 
upon where the peritoneal is incised; one may go too far and 
incise the cyst without knowing it or on the contrary taking the 
modified peritoneum for the external wall of the cyst one sepa- 
rates it from the other layers of the wall, in the idea that peri- 
cystic adhesions are being liberated. 

There is a very simple means of avoiding these two operative 
faulU; it is, when in doubt lo increase upward the abdominal 
incision: in prolonging it sufficiently, we arrive eventually at a 
point where the peritoiieuni is free, ft is easy lliun to find one's 
whereabouts and to continue the operation. 

There is an advantage in liberating the [larielal adhesions 
before puncturing the cyst. 

The stretched tumor gives to the operator's hand a resistant 
base on which it glides, insinuating itself between the tumor and 
the wall, thus facilitating the detaching of the adhesions. 

The visceral adhesions are treated as usual; we will not return 
lo this point. 

Included Cysts. — Inehisive cysts may be in the ovary or 
parovarium. In the former inclusion is incomplete; it is, on the 
contrary, always complete in certain intraligamentous cysts 
whose origin is still discussed. The course to follow is the same 
in botli cases. 

In presence of an included ovarian cyst, commence by 
looking for the two vascular pedicles which are no longer united 
in a single cord, as in tlie usual case, where the cyst by its 
development, has stretched into a pedicle the superior portion 
of the broad ligament. These vascular pedicles do not always 
appear immediately above all the internal pedicle, whose dis- 
associated elements twist over the external surface of the cyst; 
in these cases, one is obliged to successively tie the isolated 
vessels. The ligatures having Ijeen in.serle*l, the two pedicles 





38fi 



OPERATIONS ON THE TUBES AND OVARIES 



are ilivi(lc*<l iiiterti»I and cxtiTiial l«> llie cvstu' iimss: thev are 
united by a circular incision which circumscrihes a large |>iTil- 
oneal collarette urHiiiul tin- |Kirlioii of the included cyst. Apply 
fort-ipresKure Foi-ceps to this collarette as landmarks and then 
commence the sejwtration »f the cyst. We must take care in this 
fn-eiiiff of the intralijjamcntoiis portion of the vysi not to lose it so 
as to avoiti wounding of tlie ureter, uterine vessels or even the 
lar^> intestine.' 

In the cystic productions of the broad lii^ament the enuclea- 
tion of one or nmny loculi is ihiin* with the same principles; 
follow the cyst wall without l>eing separated from it more than a 
millimeter and that without preliminary ligature of the vascular 
jicdicles. It hapfpens often that one removes in toto the cystic 
pou<*h without having to use a single ligature. 

When the cyst is removed, which is no other than Uie broad 
ligament imfolded, .secure the hleeiling points with care in this 
cavity, which is then i.solateii from the general peritoneal cavity 
by suturing the two serou.s layers tojjelhcr. If oozing .still |>er- 
sists in this cavity, niarsujiiali/e it to the whII »m) drain it. 

Accompanying lIyslcrecfomy.~U\ the case of bilateral cysts, 
it is indicated to remove the uterus with the adnexa: we mav 
include hysterectomy also in the course of the extir|>ation of an 
included cyst. In cases of bilateral included cysts, Olshnusen 
urul FriLsch advise the sy.slenialic preliminary removal of the 
uterus; tlie extirpation is thus sim]>lilicil. 



I 
I 



I 



i. Conservative Operations. 

In the presence of inflammatory lesions of the adnexa. we 
may do a certain numlKT of conservative operations' which may 
be carrie<i out on tlie lubes or ovaries. 

Conservative Operations on the Tubes. -'ITic simplest of these 
interventions consists in the fnxituj of aJhcfumy. If one finds a 
lube whose size and ainsistencc are not at all changed, and 
wbase infniidibulum still remains permeable, but which has 

■ Arc TrralnMnt nf Tiunori. 

■ iloDlaiiA. Contri)>itlli>ii to t]i« Rtudv o( It^inoic ]tt«ullH of Consnvatitv 0|M>ralian« 
on (Jie Adnex*. Tit dt fan; IHBK-IS^9. N>. iVH*. F. N, Itoyil, ('onurvBtivr SurRrn- 
ot Um l^bc* UK) Oir«ri(«. Jaurnat nf Obi. and Gun. of ih« Brilitlt Smpirt, LuikIuiL 
1903. T. III. p. 341 (Ulb.). 



I 




CONSERVATIVE OPERATIONS 



387 



pn>l»|MH'Tl itilo llu* iHHH'h of DoukIhs aiul is more or less adherent 
to the pelvic peritoneum, it is sufficient to hreiik down the 
adhejiions and return the organ into its nornml nitualion. The 




I 



Fia. 'iW.~iMtfta\ '>«lpitij!0»toniy. 1'tiici> »f inciHiou <m thi> tube. 



IuIk* will require to be (ixtnl with one (tr two sutures in its 
new position ami is atlac-hrd to a fixed portion of the peritoneum, 
as for example the infuridil)ulo-[)clvir ligament. In other ^vonls. 




Pio. 331.— Tlie Itsp in turned buck, m^rous ourface fixed to mtous Rgrfaec. 

the freeing of tlir tuhe is followed by a mt})in<jopexy. After 
partial i-eseclion of the ovarv. the finibriK* dviirica' have some- 
times been lixed to the petlicle of the ovai-j". in order to prevent 




Kid. 332. — Tcnalii«t Ml|Miisa*toiiiy. Trncv of tlio cxcMon. 

separation of the two organs by formation of later adhesions 
(Fig. 334. Pozzi). 

Polk has endeavored to preserve tubes with catarrhal lesions 
of the mucous membrane by exjtresnon. After haWng isolated 




388 



OPERATIONS ON THE TUBES AND OVARIES 



Uie diseasecl tube with care by sterilized compresses, it is jjenUy ] 
expressed from its insertion outward so that its contents are 
expelled. The mucous membrane may then be cleansed witli 
an aj>]>roi)riati-' .solution which is injected into the pa^dllon with 
a syringe. 



Fig. 333.~Thi: tubul mucous tncmbrnnc is viilurcd lo Uit peHtonma. 

A coiiser\*alive o[>erati(in more frcf|uently ]>ractised is snlfnn- 
goslomtj, a plastic operation havinjj for its aim Uie remedying 
of the occlusion at tlie periloneal orifice of the tube. Carried 
out for the first time by Skutsch, this salpingostomy may be 
lateral or tcrniinjil.' 




t'la. 334.— Fixftlioa of the tubulur fiinbriie lo Ui« uvtu-y after partial exoUtoo of it. i 

In order lo do a laterul salpingostomy (Skutsch), one does 
an oval excision of the tubal sac and sutures Uie tubal mucouii 
membrane to the peritoneum. One can then, os we have 
already done, press back a flap of the tube and its serous 
surface is fixed to the serous surface of (he tube (Figs. SSO and 
331). In terminal salpingostomy (Martin) the obliterated 

■ SkuUoh, V<T d. dtiMch. 0*t. /. Gtb. umf Cyi... ISfifl. T. 111. p. 376. Jniwulkiti, D* 
la Balpiueoctomie et &utTM operations uonwrvatrio^s dM trompcs ul^rineH. 7 A. 
dt Lyon, fSW-lWD, No. 10. Kjtbii. Somo ooiuwrt-mtivo opemtions dc U 
d* ParU. IWI. 



tTOIU{IC. 



r 



1 




CONSEItVATIVK OPKIIATIONS 



380 



ertreimly of the inftindibulum is shaved off and then the tubal 
mucous membrane is sutured to the peritoneum (Figs. HSi and 
333). Ciado' after having reformed a tubal infundibulum 
fixed it to the ovary (salpiiigo-ovaro-syndesis). 

These conservative operations are only applicable to those 
cases where the contents of the tube arc aseptic. Are they really 
useful ? The pi-egnancies a3 ascertained by Gcrsung, Delbel, 
^lartin, etc., prove that at least in a certain number of cases 
Conce]>tJon may follow. 

In order to conclude the plastic operation on the tubes, we 
will mention a salpingoplasty made by Vidal, who performed 
on the stenosed tube an operation in all points compamble to 
pyloroplasty.' 

Conservative Operations on the Ovary. — Contrary to opera- 
tions on the tulies, conservative operations on the ovaries have 
been frequently done in France following on Pozzi's re-iivills since 
t893.^ These operations are indicated when Uie tube is healthy 




Fia. 335. — Une of tho indaion for partial rtwoation of » e/Mi« ovuy. 



and wlien a portion of the ovar)* rests intact (dermoid cysts, 
isolated cysts, microcyslic degeneration leading the region of 
tlie hilum untouched). 

One may do a resection or ignipuncture of inflammatory cysts 
with the point of the thermocautery. 

If a iMirtial resection of the ovary is desired, il is seized at its 
base between thumb and index-finger, which assures its fixation 
and a temporary hemostasis. Two incisions which join and go 

' CUdo, Semaint Oi/nitaloaitue, Pftrii, 24 Jan., 18(M. Ayrolea, S«ilpin£0-0Taro- 
Sj-Ddeaa. Th. d< ParU. Isas-I)1D9. No. 266. 

* MM, Rev. dt Si,n. Il dr fMr. obdomtn, Pftria, IMO, T. IV, p. 81. 

' CoBaull in usrliculnr ibu work of Po»i. lleMcUoD uid laniuuDClun ot ibe Ovary. 
n». d». fyM. ttit rJbiV. atriomm. Pari*. I89T. p. I 




390 



OPERATIONS ON THE TUBES AND OVARIES 



as far as hcallliy lissiio circunis<.Til>e llie diseased portion ant 
permit of its excision. This done, the wound is sittiin'd with 
fine catguts, which take up the ovarian tissue and hrinp into 
apposition the whole length of the wound (Fips. 335 and 33fl). 




Fio. 336. — ContlnuoiiK colgut aiiturc cloaing thr wounil following on pnrtml ciciMan of I 

This partial resection of the ovary has been combined with 
extirjwlioii of llie tuiie by Polk. I^-jars. Jayle.' 

The results arc far from being constant from the point of 
viewof dbiappearanceof the pains, but the functions are preserved. 




Fia. 337.— FoliUnK up of tUc ut«ro-uv&r{aii ItjcanHtnt In a ckm or prolapMd ovnry. 

Martin wlio has done a great number of the operations notes 19 
per cent, who Ijecame prcjjnant after the u[ier»tions. 

Ovariopexy has lit-en done in cases of healthy ovaries which 
have prolapsed into the rectu-ulerlne cul-ile-sac and become 

■ BI&gDv. SalpiDgMtomjr with l'»rtUl Uviiriectomy. Th. tU Paris, 1809. J»y)e. 
/>rarac mUicale, t)«C. 30. I8W. 




CONSERVATIVE OPEKATIOXS 



301 



painful. Inilacli merely did a shortening of the infundihiilo- 
peKic h'garaeat; Bonney/ did a zigsui^ fold of the ulero-ovarian 
ligament (Fig. 337): Mauclaire' and Harrows^ transposetl the 
ovary in front of the broad ligament, making it pass from hehind 
forward through a split in the broad ligament, which once in 
position iti front is shortenc<l. 






n 



w 



FlO, S38. — Barrows' operotion. TrunHfjosition of the iivary in (mnl of the brosd liga- 
nuint. ShorlpninK of llic rDUQi) nnd tho i[|[iiii(Iil>ulo>|Kilvic IJjinnieiiUt. 



Among conservative operations we should mention "ovarian 
grafts," which in the last Hftecn years, after jjiiblications of 
Morris in 1805 and Knauer in 1S9G, have been the object of 
numerous works.* 

It is to-day (juite established that an ovarian graft may take 
place without com|iIicating proee<Iures, notably without va.seular 
anastomosis, but that if the autograft succeeds in more than 50 
per cent, of cases, the lieterograft siiececds only exceptiun- 
ally. These grafts are made in the peritoneum or in the subcuta- 
neous tissue. There is less pain associated with the ovar}' if 
placed in the peritoneum than if left in the subcutaneous tissue. 

As indications of the ovarian graft may be mentioned the 
complications of an early menopause, general and genital infan- 
tilism. These indications are a little Iheorelical; it is not yet 
certain that these grafts persist without modifications, as the 

■ Bonnoy, The Trutmont of Ovarinn ProTnpiio bv Stiortenlng the Round Ugament. 
TroiM. c/Ofcw. Soe., Ltindon. 19(10, T, .Xr.VIIl, ji. 339. 

■Mftuckirw, Sem- Gyn.. PuriB, 1903, p. 273, 1005. p. 41, 

■Bmtowb, Mtd. Rte.. N. V,. HHli, I, VI. p. 601. At Hip nami' time m he (raiMposes 
the orary In front of tlie brood iif^iiiuiii, Dorrows thorlcnK the round >nd ioruodiI)ul»- 
ptlrie liguiwnU. 

<8Ativ^ OntriftD Cimfl* from the Surgiotd Poi^t of View. Th. de Pari*. Stcinhtjl, 
1000: Ann. de gu": Paris, 1910, p. IDS, 



392 OPERATIONS OK THE TUBES AND OVARIES 

persistence of a tumefaction is not the certain index of a per- 
sistence of the graft, as all the secreting tissue may disappear 
from the organ and be replaced by fibrous material; the fact 
that pregnancy may occur in a woman after a graft, where 
both ovaries have been removed proves nothing, as the removal 
may have been incomplete and a third ovary exists in 4 per 
cent, of women. 

If it is considered that in a certain number of cases an ovarian 
graft has been removed on account of pain then in spite of its 
simplicity the ovarian graft as operation should be abandoned. 



CHAPTER V. 



I 



I 
I 



ABDOMINAL OPERATIONS FOR DISPLACEMENTS AND 
DEVIATlOriS OF THE UTERUS. 

Summary, — Anterior alxloininnt hysteropexy.— Indirec-I hysteropexy. — 
I Dtra-abdotninBl shortening of the round ligumrnls,— ^Cunco-hystcrectomy. 
Intra-abdominftl short<-iiiii(| of the uter^xacral h^ainents. 

Numerous abdotniiml ojwrations have been carried out for 
displacements and deviations of the uleinis and they may be 
classed in two large groups. 

1. Oixrations carried out directly on the utcru.s. 

2. 0]>eration.s on the ligaments. Finally the uterus may be 
redressed by partial exeisionsi of the uterine muscle. 

1. Anterior Abdominal Hysteropexy. 

Anterior abdominal hysteropexy is described under the names 
of hyslerorraphy. ventral Kxation. .su.spen.sion of the uterus, and 
consists in the formation, between the uterus and the abdominal 
wall, of adhesions constituting a sort of suspen.sor)' ligament for 
the uterus. 

At first extraperitoneal fixation was done by pushing tip the 
uterus with two fingers in the vagina against the deep surface of 
the anterior abdominal wall and then taking it up with a large 
curved needle, [Missing through the whole Ihickness of the non- 
excised wall. 

This led to numerous complications and fell into disuse 
and was succeeded by un ititra-abdominal o|>eration which per- 
mits of the exploration of the pelvis, the breaking down of ad- 
hesions and the passage of sutures through any given part of the 
uterus. 

Operation. — The [)atient being in the Trendcleuliurg jwsition 
an incision 4 or 5 cm. long is made, stopping at about 2 cm. 
from the pubis: we may also use a transver.sc incision of the 
abdominal wall. 

303 




FOR DISPLACEMENTS 




to fix tilt' uU-nis to tlic wall. 

been devised, from Ihe point 

■lerus to fix, and the nuinU'r of 

the siis[)ensor}' suture should 

of the portion immediately above 
of the posterior face, every inter- 





im.— AUoBtiMi liyMoropoxy. 

IwMi fact!. The two extremes already 
_ _kf ISntc, Delliet and Kelly resfjeetively. 
iMwnlly empJoyetl i^roeedures is that of 




of several slitclies. passed through 

otcni^, the hi>,'he,st u]) Inl-iiij^ plaeeil l>elow 

^tafac». the tliree or four sutures being diHtaiit 



successively plat-ed. their ends being held 
l^ng tied; Ihey traverse Uie entire thickness 



ANTERIOR ABDOMl.NAl, HraTEROPEXY 



305 



I 



or the abdominal wall with the exception of the skin and fatty 
sui>cutaneous tissue. Before tying them one must he quite 
certain that no loop of intestine or [liece of epiploon lies hclween 
Ihe uterus and the abdominal wall (Fig. 839). 

In order to get a firmer attachment of the uterine wall to 
that of the alxhinieii Ixro[)old has advised Ihe scraping of the 
uterine surface ;Thiriar advises the denndation of its surface with 
the same olijeet; aljsorhahh- or jmrlly ahsorhahle sutures are to 
be used and the whole or most of the ahdoniinal wall has been 
taken up in their Inop. 

On the contrary, other ojierators only take up a limited 
portion of the uterus and the cellular tissue immediately sub- 
jacent. This is Kelly's practice, who says that he gets adhesions 
which gradually stretch and finally form more or less long 
frcnunis which maintatti the uterus in light antcversion, but at 
the same time allow it a certain mobility. 

Tlic incUifld of ili»<[>asitiuii of the suture varies inBnitcly: the majority 
of o[HT»lur« (iliict- tin-Ill tninnviTBcly, wliilc other* nmke non-jienetralinj; 
sutures for a short distance in the uterine tissue (Terrier), while olhcn only 
make up one suluri- (t'wniy, Kflly): I.cj;ueu |)lar('« his xtitches as Cuyon in 
nephropi^xy, doing a sort of Immniock suspension of tlic uterus.* 

Poxzi fixes the iilenix with a continuous suture. 

Others pass their sutures vertically, inserting two sutures, one to the right 
anJ Ihe other to the left of the iiiertian line (Zinsnieister). or three, one in the 
middle, on line with the inferior an^jle of the abdominal incision, and two 
hiteral (Faucon). 

It has been advised to insert a pessary or do vaginal tam- 
poning after the operation in order to support the uterus for 
some days. This ap|H-urs to us to be useless. 

In women after the menopause. Harries has advised fixing the bo«iy of Ihe 
uterus in the substance of the uterine muscle. He sutures the edge of the 
incision of tho parielal peritoneum ri^ht around the uterus at the junction of 
body and cervix. Then he draws the fundus of the uterus down toward the 
utahilicu.H, denudes the anterior face and fixe* it to tlie fibrous lavers of the 
w»U.' 

' Voir Harlninnn. Cliirtirgie rf«« nnjanM gtniio-uHnaIrM de I' kommt. Pari*, G. Strin- 
lt«il. 11104 

'PhiluDiln A. ItArrin. Intrnmtirn) !<(Kiucj>triition and Fixation of the Corpua and 

■ ■" Am.J.;/OI>^i.. N, v., 1910, T. U.p. 3ii, 



:i94 



ADDiiMlv 



::" _i EMEXTS 



XothillK Illnn 

The most viirinii - 
of view of tlic -' 
hivers of tlii' \\-' 

From llic ;i 
the isllimiis In ■ 



" 



Illfl! 

Oil. 
T. 

tli- 



The operation is one 

"-- >?inote results slumld 

riiopedics, therapeutics 

■ -iie results are jroor in 

- . . Q-e to remedy a simple 

■- :'.'^-ever, of no use when 

■^T-nleviation conij>lieatin{; 

.._T "ime do a reeonstrucfion 

-V. [hey are equally {^ood if 

- r.able; unfortunately, it is 

E:-.-ompIicated deviations sis 

--' :o no functional troiilile. 

. - ,-.t'xy will depend to a jjreat 

■.I'i troubles which corn|>licatc 

■> not very tight, it will 

V :.-;h may cause nil inti'stiiial 

- •■;i "..'ns are most often done in 

- .. i: the menopause and heiu-e i) 
-'^■^".ts on the obstetrical future. 

>~ 1 ■. 7e:;naucies after hysteropexy.-' 

-> ■i'^' have Ix'cn 3(i abortions, nr 

—.•.:■'■ I'f these abortions have bc<'n 

- ■■x: :hat in some cases after one 

* -■'}'. pregnancies at term (Nejiri. 

-!■<■ ;tr\\irnancies terminated in prc- 

^-.. *:th details. Andrews fomid 111 
.-«. :irxvch. three uterine ruptures. 

,. ,t NoWe. ^lilaendcr, Kushicr and 

« • .li,.' .■•.■»'i>'n sutiirr- Uii' |iiTit"iu'nmiif llic iitiT.i- 

^ j^ -vslcMi'i'si"! utvnis. Arthur Wiillai'i", A 

<-,.Tx. Vixalii'ii "f ill'' rri'tiiM, J'liiriiiil >•/ OI<.'i. 

~. - ., ', f-;»l ri^!i''i"' "I ''i'' I ''■'■'I*""' ''"''*'''|"''"' 

, ^ ,- ;;il7i C:i^">=. J-^irtutt nf tlhxt. iinil li'/''. "t' 

*"~.^ij^- »;*,,: Hv'ili'Miiii'.y iinif ils KlTfi'l mi I'lci:- 

,j;^ ._. ^S; Si'iiJiTt. /.■ '.n'lir, fur ti-U, um! Hi/-- , 



— — 5» 



ANTERIOR ABDOMINAL HYSTEROPEXY 



307 



Mnntandon show a lotal of 386 pregnancies with 44 abortions, 
nine premaliirtr luhors, and 87 imtholu^ical iahorn.' 

It appears that the operation leads to a fair number of noruint 
pregnancies. One point is established and that is that these 
complications are in i-elalion with the manner in which the 
operutioii has Ihhmi executed and that thri/ are more pronoimced in 
proportion as Uie fixation of tJie orijan is more solidlt/ fixed and tite 
nearer it is fixed to its fuvdiix tir pontrrlor face. 

In a general way, one finds the cervix siluatc<I high up above 
the promontory; during labor, uterine contractions are directed 
toward the saa-um instead of following the axis of the pelvis. 
By reason of the fixation of the fundus of the uterus, the expan- 
sion of the anterior wall is prevente<i; tlie anterior wall is hyper- 
trophicd. but it is folded back on itself and forms a hai-d mass 
above the symphysis (Fig. 340} ; the uterus only dilates at the 



I 




Flo. 340.— Pregnancy in n uterus fixud to ihe ontorior abdominal wall. 



e.tpense of its posterior wall and takes on an irregular shape. 
The dystocia ob,Herved are the consequence of these uterine 
^deformities ; the extreme thiiming of the undisturbed posterior 
vaU is perhaps also the cause of inertia uteri whicli has followed 
Cesarean section in a certain number of cases. 

In consideration of these complications, it will be understood 
why (he pregnancies of patients who have had hysteropexy 
done should be carefully watched. If from the commencement 

' MonUnilon, Abdoniinftl Hyslt-roiiexy or lotnpcriWneftl Shorteulns of tbe F 
LiganiMkU. Tliiie eU Grnivt, 1607, No. 160. 





lyS iHDtl'SfESAL OPERATIONS FOR DISPLACEMENTS 

-Jier»? xc^ viji)I«»t pains, if the uterus dilates asymmetrically, its 
■.■-r^ji 'Hfimr •iI!^placed upward and backward, there should be no 
iie^cidun: j:^ ■ioon as the seventh month is reached open the 
iiitioinea iaii break down the adhesions in order to permit the 
iterLi- to -ievelop regularly. If the seventh month is passed 
■v;uc "tntii term. At this period endeavor to break down 
itdie^iMiis, which will permit of the immediate elevation of 
:b.v -»unius. the refJacing of the cenix and the accouchement 
" - -iijf ■iiirwru/t'jt: if this breaking down of adhesions is im- 
■H>5*ii>»e'io 1 Cesarean section. Ehzabeth Hurden' has published 
i\f -^t?*?* ot the breaking down of adhesions at term, with no 
-tiaii'"iai 3iortaIitT and a fetal mortality of two. 

XamiaDaos have been, above all, applied to retrodeviations if 
;uv si-'twar to be the cause of varied troubles when there are 
■•.• ;c"uitan*"inj; lesions of the adnexa, of the cervix, or of the 
:.( "vv -imwus membrane or when the congestive phenomena 
i»-i.v;tr y "v oaujjed or at least kept up by the circulatory dis- 
!i!-'in;i-v -e<uitiui; from the retrodeviation. It has been prac- 
i^.; 13--* ^-iHijiirmentari/ operation after a vagino-perineal plastic 
'vv»iiviii n ijnfer to remedy a retroflexion complicating a 
-.<-•...»»■»*■ .liter a unilateral removal of the diseased adnexa in 
.>.v u iiaitttaiu the uterus in a good position and to prevent 
■1. '!».•• Mis; "'eiiind to the raw surfaces of the pelvic floor; after 
■ ; »-.us4^«- .'i- .»« am^mtation of the cervix in a patient witli 

■uvUt.uiu 'lifcs ap^Jietl it to the treatment of uterine anle- 
. .. ■. , (K- t\.-4[iott of the uterine body in a fairly high position 
s, »'sM.>- f>v tevvu and causes the painful symptoms to cease.- 



-j. Indirect Hysteropexy. 

1 \ \.>'.^ ^\e* the uterus by means of the tubo-ovarian 

...,>^ v'i>iMii,-*'u bv the internal |)ortion of the round 

.V '■* j„\,,-4rterl>v the anterior face of the broadligaments, 

\, .)> »* ■iMvwiure* should I)e abandoned to-day for that 

^ . ;,, ^.me m*.>».lifieations which has been adopted by 

, , . , 'v ■vnvta t'vJkiwinut Ventral Fixation of (lie Ut«ruB. Amrr. J. of 

V viciittW Hv«ten>|)exv in the Treatment of AaWBexion of 
"... A lW , IJisW. ('- 233. 



INDIRECT HYSTEROPEXY 



390 



Doleris, Riclielot, Gilliam, Mayo an<] oursolves.' The oi>era- 
tion consists essentially in a shortening of the round ligunienLs, 
after nicdian incision of the ali<loinvn, with inclusion in the 
substance of the aWominiil wall of a part of their length. It is 




I 

rFie. 34l.^nie rouml liunTiiont ik 
dravm tlimuKli n buttcmholc mmdv in 
tho ivctiiK mutdr. 
•I 



Vx 




U. 



mciiiA ill (rout iif the iDlproal portion 
of th<- rrcti iiium^lcn. 



I 



the proeefhire that removes them the least from their natural 
stale that hius become known as physiological hysteropexy 
(Doleris). 

' nol#rii>. t.tt Gf/nifnioijir. PiiriH, inOfi, |i, 491. Fuiney.TrMtniMil of RaUodtiiatioiW 
br Doli^riH McrtliiHl. Tli.de Paru, 11HX). (iouin. AdvMilii^o of Hvstvreetoiny ftom 
Uiir I'liiiit »( View of OtMrtirIric]>. Th. dr Pari: IIKM-IOOA, No. ii'vl la Uynirr^otia. 
V%tw. A\ig,.. 190S, p. 289. (iilliatii. RuiithI Lignnmil VpntMauitpciisloi] of llir L'toniM. 
Am. J. of Oh*t., N. Y., IIHM). T. XLI. ii 290. I'prtr, Vnleur mmpurfe de In-st^-ropeiy 
mMtale. TA. JrParM, IIKI.I-IIIOII, No.'in^ tlnroM'ltarkor. Rr^iiliitof .Mavo'i Modifiok- 
tlimof nUliaiu'HOiiprnllou (or i^liorifmnjc th*' Hound ygnnipnlA. Zfo^'ui \ird nixd Surg, 
Jour.. Sept. J, 1909. p. 322. CliL-vrirr. Ann. dr tlijn.. I'uris. I9I0. p. 2X7. Poullet. 
Tondinous Hvntrropnxy. Congrii frnniam di- Chitutjftr. tnos. ]>. 2iill. piiwi-ii Ihriiiigh m 
ho\« niadi- in tlicnntt'riorfold nt ihv l>rDad li):aiiii-iil. a baiid ilctiii'lic<l frum thi- ti-fidonof 
^e reotuD alHluimom, Ue tmitua it to Uic ruund liipiBirat and tlicn «utum tbu Ivndin- 
oiM band to the pulH«. 





ABDOMINAL OPERATIONS FOR DISPLACEMENTS 

Operation. — The commenccmcnl of the operation, freeing of 
adhesions, and redressing of the uterus is as usual, only the 
mode of fixation ditTers from that wc described in the technic 
of direct hysteropexy. • A 

Each round ligament is seiKciI 8 or 4 cm. from the cornu, a 
point, where even in cases that it is llltle developed, it is a firm 
and resistant cord; a chromicized catgut is passed around it. 
Strongly retracting the anterior lip of the incision made in the 
anterior aponeurasis, the surgeon inserts a pair of Kocher's 
force|>s in between the fibci-s of the rectus nujselcaml [lorforales 
with it the peritoneum. He then takes the long calgut ends which 
encircle tlie round ligament and <]raw.s with them through the 
muscular buttonhole the round ligament. The two ligaments 
are sutun'd together in front of the muscle. The abdominal 
wall is reestablished in its different plane*, and we arc careful 
to take the round ligaments with the suture that unites the 
anterior aponeuroses so as to obtain a complete fixation of [>arts. 

Indications and Results. — -Indications are those already 
given for direct abdominal liysteroj)exy. The results are ex- 
cellent from the orthopedic point of view, and are as good as those 
of direct IiysleroiK-xy. Tliey are very superior to it from the 
point of view of pi-egnaney. as this means of fixation does not 
interfere with the progress of tlie gnivid uterus. 




Flo. 343. — SbiMterdiif o( th« round ligAnwaU by Inuiaven* (ol(Iiii(. 



3. Intra-abdominal Shortening of the Round Ligaments. 



The procedures concerned in intra-abdominal shortening 
of -the round ligaments are very numerous; Ihcy may be classed 
in three groups. 




I INTF 




INTRA-ABDOHIXAL SnoitTGXIXO OF TlIF ItOUXD LlGAUENl'S '401 

1. Simple Folding of the Round Ligament. ^Vy lie makes a 
transverse TuUl iiiul tixir.s it. after having <]t-ini(]ed itii concave 
surface (Fig. 343) ; llugj;i does it vertically with the convexity 




Fia. 3il. — 8borl«uIug of the roiuid UgUDeoU by vertic«l foUUog^ 




Via. 346. — 8hi>rtf>niiig ol tJi« round ligntnontB hy folding up. 

Upward (Fig. 344). Formerly we gathered up the round Hga- 
tnent into one mass, like an accordcon with a lacked stiU 
(Pig. 345). 

2» 




402 



ABDOMINAL UPEIUTIQNS I'OR D1SPLACEUEXT8 



"i. Folding up and Fixation to the Anterior Wall of the Uterus. 
• — Polk ili'iiudes the iiitiTiml wnrfaci' uf tlie I'ouiul ligHiiieiiU alxnit 
SO or i5 cm. from their uterine end. lie brings them together 
in front of llip iilenis mul siiture.s one to ttu' other and tlien lo the i 
anterior surface of tlie uterus. 




Fio. 34S. — Folding up and fixation of the round ligunicnta lo tho uitfTJor Mirfiicw of Uie j 




Pio. 347. — Tbfl round Ugameet (■ dnwn tMokwud Uirougli m liole In tite hnini Ugaatat. 



Palmer Dmilcy denudes an ovale willi its large axis vertical, 
in the middle |»art of the anterior fiiee of the uterus; the round 
ligaments arc sutured together and to this surface. 

Mengc draws out a loop of the round ligament and inserts 
it at the level of the oritice of the inguinal canal, which brings 




INTRA-AnDOMlNAL SIIORTENINa OF THE ROl'ND LItlAMEN'n* -103 

the uterine cornu in contact with it. He sutures the two sides 
of the loop of the ligament together and then to the anterior 
surface of the uterus. 

3. Folding up of the Round Ligaments and Fixation of the 
Fold to the Posterior Surface of the Uterus.— Tli is fixation back- 
ward has been done in different ways. When one has passed 
the folded round liganiciit above tlie up{>er border of the broad 




Fio. 3<8.^The two round ligniiiouts are dmwn together iMthind tho uUinu. 

ligament, it is passed through a buttonhole in the latter and 
fixed to the niithlle or lateral part of the posterior surfaee of the 
uterus and in the former case the two ligaments may be sutured 
tfigctlier. 

Baldy's' procedure is the most universally employed. It 
was <les<:TilH'd For the first time in 1892 and it has at last Ijeen 
taken up again. In France Dartigiies and Caravcn* practised 
il with success. 

Raising the u[>per border of tlie liroad liganu'nt with two 
fingers of the left ban<l, take a pair of forceps and perforate the 

*J, U. Bulilv, Trititmeiit of Rclro-uterine DiHpUcemetitA. Sun,, gvn. and obtlel., 
Oiiewa. 1909. T. Vltl. p. 421. 
* Dartijcuo and ('nraven. 



404 



ABDOMISAL OPERATIONS FOR DtSPLACEMEXTS 



ligament from behind forward, in the avascular portion, near the 
border of the iit*'nis, and below the iitero-ovarian ligament. 
Then seize the round ligament about 3 cin. from the uterine cornu 
(Fig. 347). The forceixf draws through the hole in the broad liga- 
ment the loop formed by the round ligament. The operation 
i.s concluded by suturing the two round ligaments together and 
then to the posterior surface of tlie uterus. 





Pig. $49.— Suture of the two round ligitnii?Ql« together and to the poaterlor upcct of tlie 

iiicru*. 

4. Cuneohysterectomy. 

'I'biriar and Jonnvscu havrcanicil out tlK-iinicRilurp known as OHlerior 
cuneohijtlrirctomi/' for n'lroHexiiin. 

'l*hc o|>criition oonflUts in dimitiLsliing the length of tlie anterior wall of the 
utcnu. After incmon of the prritonciim, 2 or !^ cm. of this wait are denuded 
retracting the Madder with the inferior part of llir incised sernii* nienibrane. 
Two curved Iran^vme inri.sionn circumscribe an ellipse on the denuded area 
whose Hmall axU measures I 1/2 to i cm. and the (urge Iransverw axJa b 
al*out the width of the organ, without, however, rcacliing its Ixirders so thai 
the vcsNcb there are not injured. A eunciform segment iit rcwcted at this 

* Int«niatina«1 ConnrcM of (iynccolog}- and Obatcirios, ItruMelH, 1802, p. S13. 
nCMO, Surreal Worlo. ISW. p. 11. 




CVS EO H YSTE RECTOM Y 



40S 



levrl iind (?oni|>riM--'C thr whole Uiic-kiii^.>t of the inu.scuUr wnll without lnktii){ 
up the mucous tnemhrAne. Thn'e or four calgul sutures unite thi: lii^ of the 
inri-'«iiiii: il second Inyer of suture:* hririgs together the lips of the peritoneal 
ineision. 



— - - . - J 



7 




Fig. SSD.^Cuneofajwtcraotomy. Donu- 
dftUoD and psnage of •titohM. 



I'lu. 351. — Cun«ohyatereoloiny. 
DperAliOD tcrminntnl. 





Fie. 3GS. Flo. 333. 

SbortwuDS of the Dtoro-MOisI liK^moaU. 



We iiiny compare PestaloznaN* operation with thU one. .At the upper 
limit of the inferior segment of the uterus, Pe»1»l»zjui ineLses on the anterior 
«urfuee the Merou.t nieruhnine iin<l the subjacent muscuhir layer. He 
separates the flap vrith his finger as far us the level of the vesieal clonic and 
tlicn pait-iinf; » wuture thrnugli thi.- uiiterinr !>urfaee of the antcflexed uteruit, he 

■ Petlnloiui. Per la ctira Openitlvii dclU Ittrtrotli-MJonu Ulorlna. Atti dtUaSoc. UaL 
fobii. t. fin., T. XII. au<l Montuuro. Zmn.-Bl. /. 6'yn., IVIO. p. 497. 




406 ABDOMINAL OPERATIONS FOR DISPLACEMENTS 

traverses the middle of the flap. A series of secondary sutures are inserted 
laterally as far as the broad ligaments so as to completely close up the 
denuded surface. 

By passing the sutures more or less high up on the anterior surface of the 
uterus, we obtain a more or less extensive area with the flap and we can thus 
determine the degree of anteflexion accordingly. 

5. Intraabdominal Siortening of the Utero-sacral Ligaments- 

The uterus having been drawn forward and upward the utero-sacral liga- 
ments are rendered tense and one or more sutures are placed on these liga- 
ments; the sutures are passed from without in about 2 cm. from the uterus 
in order to pass again through the ligament from within outward at the same 
distance from the rectum. When tied, we get a folding of the ligament, 
which is thus shortened (Figs. 352 and 353). 



CHAPTER VI. 

■ SOME RARE ABDOMINAL OPERATIOMS. 

Summary .^Olilit<>ration of the jiouch of Douglas. — Lif^aturv <>f llic 
utrriDC arten-. — Lignhirc of Ihr lir]io{;a9itrk wins. — Keduction of uUritiP 
invcrHon. — (\stopexj-. 

1. Obliteration of the Pouch of Douglas. 

Marion, who invented this operation for certain cases of prolajim; wilh 
rxnggernted cieo|n'nii)g of tht; pouch of I>oiigla)i, advise.t it to be done as 
follows:' 

The uhdomcii heing opened, the pelvu einplieil of it.s intestinej. he draws 
Itie uterUR forward and then proceeds to the oblitenilion uf the pouch of 
Doiigluv liv iiii-uris of four pune-ittring xtitures of increasing diameter in the 
peritoneal eul-de-iiac. 

In order to insert these .sutures he tiegin.t hv seizing the floor of the cul-de- 

with forceps which draw it upward, and then places completely around it 
■■ft sul J peritoneal suture which he ties afl«r having taken off the forceps. The 
first suture is drawn upward in its turn, which permits of placing a second, 
and one can then !succesflively di.'(|K>.sc of n iwries of four or Bve sutures accord- 
ing to the depth of the cul-de-sac. 

These sutures ^Iiouhl take liohl not only uf tlw peritoneum on the pos- 
terior surface of the vagina or the uterus, but equally on the sides, tlie serous 
memhrnne that elotlies the pelvi.i below the white line. 

The insertion of the deepest stilches is quite a delicate undertaking; to do 
it best, the ogn-rittor HJiould take bold of tbi- peritoneum wilh a long pair ni 
forceps for holding tampons and then insert inio the fold thus produced the 
suture nee<lle. 'rbcii)M-rleil>nluri-H should gnn.-v high as ihe ponlcriiirfacc of 
the uterus. The only precaution is to guard against completely perforating 
the coat* of tiiv reetiMii. 

Thus the pouch of Douglas is obliterated. The cervix is drawn back* 
want and adlu---<ions between it and the rectum and |>eriloiieum of the 
postcro-latcral portions of the excavations are produced U'"ig»- •''^■* »'"' 555). 

This proceilurc. to us, secnis above all applicable to "false prolapse," 

' RauBM>au. Troatiucnt of Oertaio Cases of ProIapM by ObUterattoa of tlte Pou«li o[ 
DouglM. Th. de I'arit, 1908^1900, No. 7. 

407 




408 



SOUK RARE ABDOMINAL OPERATION'S 




Pio. 364. — ObUtnatton o( ilic pouoli of IXidgliw. 




Fia. SS5. — OblitcmtiiMi of tli« potwh of Daugla 



UUATl'KIC Ol- THK I TKKINK AKTKUV 



400 



thci»e cases in which then* is » rcut hrrriin uf the iioui*!! of Douglas, aomftinics 
coiifu-trij uitli lru<> |trol»]isv. It i.i goud. nc livlieve, to combine it nilh a 
posterior colporrhaphy. 

2. Ligature of the Uterine Artery by the Abdominal Route. 

Th<^ uterine iirti-rv, the It^j^alure <if which Khh ht^n advised in certain cuitca 
where slropliv of tumors' is desired, may l>e done in two nays: 

1. At theJ^vel of Ihr Orarian h'tmsii (Hnrimiinii and Fredet). — Thv Innd- 
luark in Uiis operation is the constant relationship of the uterine artery lo Uie 
iireler at thr> level nf tlic llttlp fossa iif llie ovarv. 




Fio. 356. — Tli« pnticrit ic ]>laco<l in tlii> TrMKli'li^tibur); puoitiun At lui wigle ol 4a deftvea. 
Th« Sgan sboim the rvUtioa of t)t« uterine artary to the urotcr in ths ovDri>n foxa. 

The hypogastric aricrj-. up against Uie osseous wall of Uie pelvis, bchiad 
lire ureter or in part covered over by it. gives off lliree anterior brimches, the 
obturator, the umMliciil and the uterine, which separate in front of the ureter 
under the peritoneum whidi elothe> tlie floor of the ovarian foMtn. 

■ Ilsrinuuu) uml rrrHcl, The Atrophviog LlcatiirM In tho Treatnwnt ol UMHm 
Tumort." j*».iii. A 6>i,. I"ari«. JS9S, T.'I. pp. llO-aOft. 




410 



SOME RARE ABDOMIN'AL OPEIWTIONS 



The iitt>rin« artery which fotncs off cilhcr liiph or low, or in ctiiiimon with 
the umbilicnl Mrtcn'. always appears in front irf the urinary caoa]. Thb 
conslitutrs an rxccllrut Inndmark for the flnding of the artery anil its origin 
(Fig. 356), If there Lh some doubt in the event of our finiling two vessels. 
both UTV. tied or the common ulero-umbihcal trunk is tied. Never risk by an 
incision in the ovarian fossa Uie injnrv of the obturator, which lies higher 
and more parietal tliun the two arteries we have mentioned. 

We will now deseribe how the ii|)eration Is done: 

Tlie patient having been plaeed in the TKndelenburg ptMttion. the 
ovary is lifted up with a pair uf Miim'ux's fon'ejM and the ovarian fonfui in 



tf Rjl. IF 





r£b^^ 



Via, 357. — Thin &KHrt^ is the exact reproduction of that of AltuclioS. 
The two drawinsi rcprownl u vertirnl aiiU'ro-potilericr H-ctioa of Ihc bread linnient 
atwut Ihe mid point of the lonKth of the tiihe. (i. o,, ovuian UfinBionl: I. F., FallopikD 
1ub«:l. r.. round Usuinciit: m, purl.iUuiiformlnKaoort of inp«enlerylci iho round liKaoienc 
v., uteriDc vein: v., ureter; A., uteriut- artery; p. m.. bladder. To the left, liie Fig. 1 
■tiom the part? In partition: to the right. Fig. II, shows that on clravine forward Ui« 
round Ugameot, ^e memBtery la drawn with it and tlio ntarine arreiy wblnh nomiAtlv 
in A. coniei after traction to lie in front of tlie round li^meul at A. In order to eaten 
the artery follow the course of tho arrow, 

exposed. .\t this level, below the psoas, may be seen the ureter by trans- 
ference. Parallel to it and a little in front an ind.iion i* made in the peril- 
oneum of the ovarian fo.'ua. Seizing between forceps the lips of the incision, 
separate the [>eritoneum backward a little with u grviuviil ilireirtor and about 
S cm. below the Iiriui of the peUis. the uterine and umbilical arteries at the 
point where these vessels separate anteriorly fn>ni tlie ureter. 

Nothing is simpler otiee the artery is recognized than to pa.ss a blunt 
oecdlv and suture below it and lie il. Some line 4ilk« unite the peritoneum. 
loose enough to avoid compressing the subjacent ureter: then the abdomen 
is closed in the usual way. 

2. Arronii the Uroad l.itjaoxenl (.\ltuclioff).— This procedure is based on 
the following anatomical data: 

'Iliere exL-tU in the !tub«t«nce of tlie hroad ligament a sort of partition 
wbidi mounts from tta base toward the rouod ligament, doubling the anterior 



I 

I 



UCATIFRE OF THE H^TOGASTRIC VEINS 



411 



I 



Inycr of ttie l)mn<l lif^niiiont. The ulmne artory i^ adhrreiil to tlii* sort of 
partilion and follows it whrn it is drawn forward (Fig, SAT). 

Id order to ligature the uleritie artery by this procwlHre, lifting ii|> tlie 
tube, the round ligaiuent i» dmwn forward; parallel to this and imninliately 
liebiiKl it, we make an incision of about 3 cm., the extcniui en<l of which ter- 
minates about 1 em. from the innominate line. 

Thcgrooveddirt'etori!* made to enter the subatanceof the broad Hg&ment, 
following its anterior layer, which reinforced by the "cellular mesentery of 
the round liganit-nt," give.i a fairly resi.ilnnl point of .tiijipori. At u depth of 
19 to 16 mm. one comes across the uterine artery:when recogniKcd, nothing 
u simpler than to tie it fairly high up. The ureter lieji below ami behind the 
artery; it will not be injured. 



I 



S. Ligature of the Hypogastric Veins. 

Tliis ligature has been advised and carried out with success lunce 1002 
by Trendelenburg in a ease of puerperal pyeiiiin. Frcnnd nnd Hunim bad 
already tried' without success to stop the puerperal processes from going 
beyond the uterus by tying the utem-ovnriiin veiiiji. Their course being 
checked ts explained Ijy the fact that phlebitis of the hypogastric veins i.* 
three time more frerguent than that of the utero- ovarian ones. 21 as up])oscd 
to 7 (Trendelenburg), which was confirmed by I<enhart!i. 

1. Extraperitoneal Route.— By an iliac ineiMon the peritoneum is 
separated and then the hypoga^itric vessels are looked for. 

Transperitoneal Route. — The transperittmeal route, which is easier and 
which permits furthermore of tying if necessarv the ulero-ovarian veins, is 
preferred liy Vineberg.' .\fter opening of the abdomen in the median line. 
the operation will depend upon whether it is neeessari' to tie or not the utero- 
ovarian veins at the same time sm the hy|">gaslric veins. In the former case, 
cut the utero-ovarian veins between two ligatures and prolong the jteritoneal 
incision downwani along Ihi- li-iiglh of the by|iogastric vessels. Enlarge this 
incision with the fingers and we have the large iielvic wssels expoitcd to view. 
Nothing is simpler than in tie the inlernnl iliac vein, which is to be found on 
the right behind and to the outside of the artery and on the left to the inside 
of the artery. If the uteru-ovnrian veins are healthy, make an obhque inei- 
dion on the posterior surface of the brtiad ligaments like that of Wertiieim in 
his radical uperalion for cancer. Then separate Uie edges of the peritoneal 
incision and we find thai we ha\-e a liberal acnrss t» the bax; of the ligament 
and lo the large jjclric vessels contained in it. 

' Tpendtlpnlmrit- Mu'ifh. mrd. \\'a~h.. \9\ri. T. XIIl. 

• Vineberg. I.injition of Pelvic Veina for tuerperoi Vytaaa,. Amtr. J . of OA«r., N. 
IBOW.T. I, p. 412, 




412 



SOMK RAKE ABDOMINAL OI'ICILVTIOVS 



4. Reduction of Uterine Inversion by the Abdominal Route. 

f iHillnn) Tlimiiiw, itflcr In- litiis tiin-noil lln- nii<l<mi(-ii, iiitrfxliKrH hU iiiilf\- 
finger into the inverted uterus, and then guides along it a dilating forc«t 
which pnhirges thu ccmx nnd renders luxLs «xsy. 

Tliismetliod. which enables us hy sight and gialpation toGndout the state 
iif rijii tract ion of the cervix and of the form «nd extent of the ndho^ionx, 
ajipcars a priori to be the operation of choice. 

In reality it ha« given few good results by reaxon uf the difficulty in iliUl- 
ing the cervical rioj^ and because of the necessity of often splitting it. It is 
Miiiijiler to 0|KTate by the vaginal route. 

In 180S Everk proposed a mixed procedure by abdomino-rnginal rmilr. 
lit- npeii^ the nbihinien, s|iIil-< the niiti-rinr khII of the uterus ak far nv the 
bladder, and if the reduction is impossible he splits the posterior wall as fur 
ivt the invortioti uf the vagina and then reduces it with the vaginal hand mi 
the fundus of the uterus. He concludes by suturing the anterior and |kis- 
tenor uterine incision*, tlien Gxv* Ihc organ ti> the nntcriur abdominal wall. 

5. Abdominal Cystopezy. 

Abdominal cystopcxy has been done by a certain number of operators. 
Tilflii-r (ixcs the bladder by its extra peril onea I pari above the pubi^. Ilj'ford 
fixes it on a line with tlie inguinal rings; Laroycnne commences by doing ao 
abdominal hysteropexy and then sutureit tlie postero-inferior wall of the 
bladder to the anterior face of the uterus, and its anterior wall to the abdom- 
inal wall below the zone of lixatioii nf tlie utenis.' 

Dc Vlaccos. Dumorct' and Chiavcntone do an intrnpcrituneal fixation. 
Chiaventonc. after inei-sioii ttt tlie ve:ticO'Uterine fold, .teparate!) the bladder 
from the uterus and from the vagina up to a point where the dense connective 
IJKSue taki\H the place of the loi»se li».iue. He linds that he ts at (he level uf tlie 
interuretcral ligament which he takes up and stitches to the anterior surface 
of the uterus about 1 em. above the anterior vaginal fornix. He dotct lli« 
incision of the vesicouterine cul-de-sac and finishes by doing an anterior 
abdominal hysteropexy.* 

All these procedures arc abandoned to-day. 

' l.nroyiMiiiv. Trvalinunt of PrulupM liv SutpvoNioD of tlie UWni* aad Bladiler from 
Die .Vbdnminal Wnll. Ann. dt (,yn.. I'nriH. lUOO. T. II. p. MH. 

'Terrier, Anterior Abdoiniiial C>'Bt4>pexi'. lt«port on ObMrvalktns oJ VUccM, 
Dumoret anil Tuffier. Bull, ei Utm. lU la Soi. rf« Chir.. Vuit, 1890. p. 454. 

* Ohiaventone, (^topexy in GyneooloKy' Ann. de Oyn., Pari*. 1002, T. I, pp. 283 
and UA. 



I 

I 

I 




PART IV. 

THERAPEUTIC INDICATIONS IN DISEASES OF THE 
GENITAL SYSTEM OF WOMAN. 



CHAPTER J. 

TREATMENT OF IKFLAMMATORY LESIONS OF THE UTERUS AND 

ADNEXA. 

Summary. — Mdriti*. Evolulmii of |iatliogenic conerpUou and Ipcat- 
mcnt. — ^'1'. proplnla'lic. T. nirative of acute metritis, of clirfinir iiiHritix 
(gcm'nil iind l<icul Irr-ntiiu'til I.^IndicalionN of Irratrnvnt in acute and clironic 
in flam ma I ion nf llio adnexn. 



1. Treatment of Metritis. 

The trcalranit of nielritis is far from being definitely cslal>- 
lished; divergence of surj^'foiis in tln-ir opinions on this special 
point of gynecological therapeutics points to the obscurity of the 
nature of lliis aifcction. 

Here, as everywhere, thera]>eutics have always been closely 
allied to the [mthogenic cunci-ption and difl'crciit hhmIos of treat- 
ment, gradually abandoned, reflect faithfully the different 
Uieories that inspired them. 

Forty years ago, in a ease of metritis one saw only the local 
expression of a general slate: herpetic eruptions of cervix, scrof- 
iiloii.s' and rheumatic metritis, etc.. were described. 

Willi mctrilis was ranged congestion and uterine subinvo- 
lution, without exact knowleilge of the lesions one was treating. 
Tliera[K'utics participated in the uncertainty. It consisted 
mainly in a line of general treatment in keeping with the su[>- 
posed diathesis of the patient, and of applying vai-ious local 
applications to the cervix. 

Modern bacteriological work and the idea of infection abruptly 
simplified llic conception and treatment of the inflammation of 

* Mftninmu, Clinical Tnmtiiw on Uio Uterine .\fToct)ona, Pu\t, 1879. 

41J 




4U TREATMENT OF I STI-VMMATORY LESIONS OF THE OTERUS 



I 



I 



the uterus. The term metritis became svtionyinou.s with fnS 
fectious lesion of the uterus aTid the trenlment once clearlv 

• 

gra.spod, had as its siiuplc ohject, the (l)sinfe<-tion of the endome- 
trium. Various and varied meuns have been tried to this end. 
viirvinj; from .simple fintiscpfic trciituient to eun'tljige, which 
repi-csents Uie most energetic expression of antiseptic trenlmcut. 

Latterly gj-necohigi»ts have come to the conclusion that the 
role of infection has lieen exaggerated and we have a division 
into metritis an<) infective metritis, and then a variety of path- 
ological conditions known as false metritis (Doleris), simple 
chronic metritis, non-infective, hypoplastic metritis (Ooderlein), 
uterine sclerosLs (Richelot).' etc. ■ 

These non-infective metrites or pseud o- metrites spring from 
a variety of causes. Generally, it is a local eaii.se (tears of the 
cervix, prolapse, uterine deviations, tumors of llie uterus, etc.). 

Infection may have been the original cause: the primary 
microbe disapjjears. but the lesion continues to evolve and finally 
forms the dLsease without it. m 

At other times it comes from a general cause .tuch as neuro-" 
arthritis, eventually leading to a .sclerosis of the uterus. Finally 
more recently, our attention has In-en drawn to lesions of theB 
mesometrium.* cither an insufficiency of muscular ti.ssue com- 
bined with chlorosis or sueh alt'eetions as tuln'rculixsis or typhoid 
fever, or a congestion or stasis brought about by sexual excesses, 
onanism, d('fr<-tive hygiene, or circulatoni' troubles due to arterio- 
sclerosis.^ M 

The exislenee of these non-infective metrites is to-day suffi- 
ciently demoiistrate<l. but it is often difticult to distinguish 
them from chronic infective mclriles. From Ihe clinical point of 
view, the ditferences are often minimal and at times do not exist. 
An etiological i-csearch from an interrogation of Ihe patient is 
often very iiiiccrlaiii;tlierc only n-nmins the bacteriological exami- 
nation which may also Ije uncertain. 

It is certain that we should diminish in one's mind the role 



■ l(kli«li>t. SurRrry ot Ihv I'lerus. _ 

MpP 11 

\rrh / 6'yn.. Burliii. UKI8. T, I.XXX VLj). 628. 



1 
I 



> ThcUhnlxir and )iloirr, Kiir .\nAliimici. Pntholoeir luiil Ti>nipie derehroniadiMi Kixlo- 
/ Cyr,.. li 
UerUn. 1909. T. CXCVI. fnac. 3. 



invinim 



•mpi 
Hin 



DH'h, Areh./. potk. Anv., 



' t'nimnr niidlpy. Artcrioiiflcroni» of Uto riirnin n» a CukuaI I'nct in I'lflrior If^inar. 
rliiifi- f.Sm J. I'/O'ii-f , Jiilv. H'U.'i, p. T1). Ilnxik*- M, Adhiiik'Ii , Mi'inirmeia nivopnlliim. 
I'ntt. offcnn. Mnl. Hiiil.'i'Ai.. IWW, p. 323. IL L. Dickiniwii. liilr»ict<a)lf M«iiorTluici« 
oT Artcrionclcfoiiisof Ihc 1Tl»rui>, Brwi. Urd-J., IWW. T. XX. p. At. 




TRKATMKXT OK MKTIUTIS 



41S 



M infection antl not at the same time to exaggerate tlie number 
and iinportancY of lliose psfudo-nielrite.s. Nevorllieless it is 
certain tlial from the point of view of practice there exist a certain 
numl>er of cases where antiscplit- medication, with llic ohJM-t of 
destroying infective agents, is qnite useless as these do not exist. 
Finally, from the 1hera|>Piiti<' point of view, we should take 
account of ctmcomititnt Itnions, tears of the cervix, elevations, 
prolapse, etc.. which if they do not cause metritis, favor, more or 
lesii, itfi development and cuntrihute toward its support. 

I. Prophylactic TrestmcDt. 

For infective mHriiis the indications for treatment are quite 
distinct. We must cure the vutvo-vaginul infections, which may 
ascend toward the uterus. We shoidd do every gjTiecological 
exploration under cover of strictest asepsis. Aseptic precautions 
in [iregnant women have a great importance; the majority of |)ost- 
puerperal nielriies result from .some infraction of asepsis during 
an exploration or intervention during labor. 

The retained phicenlal remains may he perha])s the direct 
cause of infection as they favor at least the invasion of pathogenic 
agents. 

;\gain from another point of view, we should lake note of the 
state of the hushand's urethra. .\ number of metrites are not 
only caused by, but kept up by, gleet and the treatment of Uiis 
gleet is one of the most important prophylactic means we possess. 
Young men should be warnpfl of the danger to their wives from 
a neglected and veiy small discharge. 

In non-inffdive metriUji. in which the pathogenic is still 
unknown, prophylaxis has not advanced much. The general 
hygiene as adopted by the woman is the capital point. The 
advantage of sufficient rest in lied after an accoueliement abor- 
tion, of abstention from exaggerated or abnormal .sexual stinmla- 
lion. after nieiislrual troubles, etc.. is generally admitted. There 
is nothing, however, definitely established in the foregoing. 

U. Curative Treatment. 

Curative treatment differs according as we have to deal with 
an acute or chronic metritis. 

Acute Metritis. — We will only deal here with Iw^o types of 




416 TREATMENT OF INl r.AMMATORY LF^I0\8 OF THE TTF-Rl'S 



acute metritis, gonotrlieal ntul septic, of which the laller it 
exeni|)lifi<.'<l gciierully in puerperal mclrilis. 

Gonorrheal Metriiis.—'Vhe ti-eatment is not extensive. Th* 
[tatient is put to Iwd and given complete refiosc. Give vaf^| 
inal injection of permanf;nnale of potash (1 in 5,000 to 1 in' 
20,000). 

Secure a daily evacuation of the intestine. If there is acute 
pain, put ice on the abdomen, and prescribe mor]>hia su{>- 
[>ositories. In every case abstain from the least intrauterine intei^ 
vention liv reason of the possible invasion of tulK-s and j>er-a 
itoncurn. V 

Septic Metritis.— In septic metritis, where pnerpenil infection 
is the most frequent, repose, diet, lif^ht laxatives, application of 
ice to the abdomen, anlipyretics. general antiseptics as collargol 
or deetrurgol, and vaginal injections have been adviseil. Bui, 
contrary to the rules of treatment in acute gonorrhea, the local 
action on the uterus is our first thought. The means proposed 
to act on this organ are three: Intrauterine irrigations, curettage 
and hysterectomy. 

Intrauterine irrigations wliich may be repeated one to three 
times in twenty-four hours constitute the simplest of the means 
we possess. In slight <'ases, they give cxceHont results, above 
all if one is careful not to combine with them any tamponing of 
llie utenis which generally blocks it, but to do drainage of the 
cavity with a simple rubber drain instead. ■ 

In acting thus we do not pretend to destroy the micro- 
organisms of the uterine cavity, but we avoid stagnation and 
diminish the phenomena of ai>sorption. If the intrauterine, 
irrigations are inefficacious, we shaultl not wait, but go on tc 
curetting of the uterus which is often indicated by another] 
cause such as the existence of a retained product of the 
placenta. 

There has l>een much discussion over the indications of curcl-l 
ting in cases of puerperal metritis. 

A certain number of gynecologists particularly in Germany^ 
arc oppos<'<l to it. 

Its utility in cases of partial or complete retention of the pla-' 
centa seems to us to 1>e indisputable. In alt ea.<ies of septic lochia 
with fever, wc may always have recourse to it. The fear of-j 



1 




TREATMENT OF METRITIS 



417 



I 



I 
I 



deslrtiying the protective memlirunc uf (K-lViisc or of nol eviiciiat- 
ing nil the intrauterine germs should not arrest the surgeon. 

The somewhat rare ootii plications we have observed are 
nothing in proportion to the considerable number of patients 
whose fever ceases on curettage, free irrigation and drainage of 
(he uterine cavity. 

When the intrauterine injections and curettage are powerless, 
Ihe question of liystereciomy occurs to us. Tlicorctically it i» 
indicated after failure of simple Irealment when the uterus is 
the sole starting-point of the complications. Wlicn there are no 
infective foci outside it, .neither peritonitis nor more remote 
lesions, caused hy the transportation of septic omtwii to some 
distance, in a word, when life is in immediate danger by reason 
of the existence of an infection in the uterus. 

Unfortunately, in practice it is often diflScult to be sure that 
life is actually in danger; a patient who seems lost is better 
the next day, others who seem to be doing very well sud- 
denly show signs of l)cing much worse. 'ITie secondary met- 
astatic deposits are not easy to discover. Hesitation is, there- 
fore, necessary liefore intervention. The results of tlic opera- 
tion are, however, not vcr}' brilliant. Christeanu,' who has 
collected 137 cases, finds a mortality of <f3 per cent.. larger than 
for hysterectomy after con fine men t at full term, 64 per cent., and 
also larger than that after abortion, 4S.S per cent. It must also 
be underslootl that few surgeons are In favor of the radical opera- 
tion. If resorted to, total hysterectomy is preferable to subtotal, 
8S the infective lesions often spread to the cer^TX. As to the route 
to follow, it varies greatly; the vaginal route has been objected 
to Itecause the uterus, soft and friable, is easily torn by traction 
of the tcethe<! forceps; this objcclion fails, if in place of using 
teethed forceps we use large forcei>s with flat extremities of the 
same variety as cj-st forceps. The abdominal route, however, 
most merits our preference l>ecause it ]>ermits, in cases where it 
ap])ears necessary, of our operating on the veins of the pelvis. 
tj'Ing and excising those that are aifccled with suppurative 
phlebitis, an important point, as juxta-ulcrine venous suppura- 
tion, is far from rare in the cases that we are dealing with. 



* Cii«l«aiiu, Hj-alcreolomr )uid Acuta Puerpeml Infeotion. 
Ckir. Abd.. Pmw, 1904. p. 017. 
27 




BcPiM d« Oynfo. H 6t 



418 TREATMKNT OP IKFl.AMMATOKY LESI0X8 OF THK ITERtS 



3 



Chronic Metritis.— The treatment of chronic metritis sliould— 
1>(> grncrul an<l local at the same time. V 

General Treatment. — The importance varies according to the 
c»se. Kven when «*<• are cleahiig with a rhroniv hifrrtioH 
metritis wv: should not leave it completely on one side. 

We .should avoid all cases of congestions in the lower |>clvia 
and constipalion in particular; this latter may be ti-eated by use 
of enemas and laxatives. Repo.se is one of the first indications, 
and rest in bfd. if the .syin|>toni.s still show a certain chantcletH 
of acuteness orif there areany hemorrhages, or rest on a sofaif tli^l 
|>aticnt is a chronic; we thus avoid fatigue, walking or standing 
for any period of time. Sexual congress should be absolutely 
forbiilden. 

Wearing a Ik-Ii or appropriate corset, lifting np the lower 
abdomen and preventing the intestinal mas-s from pressing on 
the uterus is also of use. ■ 

To this hygienic treatment add an internal niediration, which 
is. acconling to the ease, simply Ionic, antiurthrilic or anii- 
lymphatic. Mineral water treatment may be of great use, if it is 
thought necessary to act on the general condition. Tlic choic^l 
of a resort de|M'nds above all on the nature of general symptoms. 
which are supera<lded to the genital troub|i-s.' 

Loral T real men f: Local Irealniciit of clironic metritis co 
sists of a .series of agents, which we \vi!l simply enumerate, ant 
we have mentioned [he teclinic of their execution earlier in thiit 
work. We will see later which agent is to he preferred accord-, 
iiig to the type of metritis we are dealing with. 

The vaginal injections are currently employed. I{ememljer 
the importance of the position of the ]>aticnt and tomjieratui 
of the injection. The nature of the fluid em]»Ioyed is only of 
relative interest. 

As vaginal drv.ixini).i we use tampons of iodoform or salicylic 
gauze steeped in neutral or .slightly iodized glycerine. We marfl 
al.so use ovules with a glycerine Iwise. This last named nierits. 
a.s a local application to the eer\'ix and vagina, a reputation due^ 
lo its hy*lnig<igic proiH-rlics. V 

Cauterisafion.8 of the cervix with thermocautery or cheniieal 

■ Sm> Miii»nl W&wr Tnwiiiwtil. 



J 



1 




TRICATMKXT OF MKTHITIS 



419 



I 



I 



agents (tincture of iodine, cliloride of zinc, nitrate of silver, etc. ) 
may I* of use. Wi- sliould iilsn use inlraittrrinr thernpeutic 
agents wliicli are applied in various forms: intrauterine pencils, 
tainponings, uterine lavage, clieiniral cauterization and disin- 
fection witli toucliinj; u[j of ttu* jmrls with forninl in a solution 
of 3(>-50 per cent.' iteineuiher llie iniportance of preliniinary 
dilatation which may besides ciKistitiile the principwl stage of 
the treatment in rendering the uterine muscle supple ami scouring 
easy drainage of the uterine cavily. 

Curettage, formerly regarded as the last resort in Irciilnu-nt 
of metrites, has now reslricled indications for its use, also better 
determined ones. 

IjP\ us mention in conclusion that the different varieties of 
amputation oj tjie cervix and more particularly am]«italion by 
Schroder's procedure or a inodified form of the same, and 
finally hysterectomy, vaginal or abilotninal, which may be indi- 
cated in some exceptional cases. 

Sueh are the local means at tlic disposal of the surgeon in 
the treatment of metritis. We must make a choice from these, 
according to the form of metritis we aie dealing with. 

In a general way. meU'ites in their primary [ihase, in particular 
lhos«! which follow on llic puerperal state, are accompanied by 
notable lesions of tlie cavity of the body; later, when the disease 
is characterized above all by abundant leucorrheal discharges, it 
ap|Kars to be entrenched above all in the region of tlie cervix. 
The treatment should be directed to the body or cervix according 
to the case. 

In gonorrheal metritis of still recent growth, if gonococci are 
found in the uterine discharge, tlilale the uterus and follow with 
liberal washing out with lukewarm solution of permanganate of 
potash, in strenglli varj'ing from I in 4000 parts to 1 in lOiMI 
parts. 

At a more advanced period, if the gonococci are rare or dis- 
appeared, we should have recourse to cautcri/jition with silver 



' 34«nge rPooiniii«nda lliin ngiMit very wannly. He rolls % thin loycr ot wool 
•round U)o •pund, uti^rp* It in fi^rmol itnil appIlM l>oUi ends aucifuM-i'ly to tho miKoui 
memlHiiDe; the firvc Ui ilruiu tlic mupoiis meoibrkDc. thvueoond to rhAnin> it- A pi«oo 
of iodoform eaiuc ii aftonvAtd iiucrtrd into tbo vbkIra to obtiuo a cauivriiutioD of ibt 
maooui membrane. The nppllcntlon cboulil be rraewed M, the end of rifcbt ilnyt and 
then St longer inlurvuln. (0. Henge, CieTbcraiMederehroniMbvn. EDdomoUitiaindor 
allgenMHneii Pnixi*. Arch.ftirGyn.. Itorlin. IWI. T. LXIIt. p. 391.) 




420 TKEATMKNT OF INFLAMMATORY LKSIONS OF THE irTERDS 



.), chloride of zinc (10 



0. 



I 



nitrale (1 per cent, to 5 per f 
tincture of iodine, etc. 

Aiway.s do a pi-climiniiry dilatation befort* these eautenza- 
tions. Between these cauterizations we may apply medicated 
pencils. 

In non-specific infective processes at their onset or hanng be- 
come secondary, the treatment varies according to the anatomo- 
clinical conditions we are brought face to face willi. 

Ilrmorrhngic mrlrititt juslilies curettage of which it constitutes 
tlie triumph. Instillatious of chloride of zinc give aUo excellent 
results in these hemorrhagic forms and may even cure these cases 
wlicrc curettage has failed, while uterine atmokau.si.s has equally 
given numerous successes in infective hemorrhagic metritis, but 
tlie difficulty of its application and above all of regulating this 
very energetic therapeutic agent, determined us to reject its em- 
ploy. One hIiouIcI choose then between cases for curettage or for 
instillations of chloride of zinc, after a preliminary dilatation. 

In leucorrhetd format, intrauterine treatment has, for a time, 
been abused, such as the scraping, injecting or uselessly cauteriz- 
ing of the uterine cavities. As Uichelot very wisely remarks, the 
majority of cases of purulent Icucorrhca is connected with lesionii 
of (he cervix, so they must be treated. 

In slight cases, with enlarged cervix or with slight ectropion 
a cure may often be very simply obtained by the combination of 
light cauterizations with nitrate of silver or applications o: 
iodine, etc., and dressings to the vagina. 

In grave ctisex we should have recourse to a more energetic 
treatment and make use of cauterizations witli Filhos' caustic. 
If the cervix shows characteristic lesions of selero-cystic degenera- 
tions, we shouhl. without hesitating, amputate it by one of tho 
anaplastic procedures we have described. 

In the lesions which are manifestly not infective and arc some* 
times describeil under the names of congestion and uterine 
scicroais, curettage and intrauterine treatment is not often of 
great use. 

For uterine congestion in virgins rest in Ijed, during men- 
struation and abstention in Uie inten'als from violent exercise l| 
(horse riding, bicj'cle and abuse of dancing) constitute the base of 
Uic treatment (Siredey). The uterine uiedicntion (hydraslis 




TREATMENT OF METRITIS 



421 



canadensis, vihiirntiin [iniiiifotiuin. pist'idiu cn'thriim and u})ov<? 
all quinine sulphate in doses of 16 lo 84 grains) render signal 
servicTs (Riclielot). 

In a young woman, hot vaginal injections at 50° C, of from 
5 lo 10 liters, given gently under low ]>rpssure. <iiniini.sh greatly 
the paiiiK and hemorrhage. Glycerine applications, electricity 
and massage render service. Iiilrautrrine ther:i|>eutic agents 
have hanlly any use in the hemorrhagic forms. 

In all cases genend treatment has a great importanre. One 
should avoid all cause of |>elvic congestion, such as consllpation, 
by giving enemas and laxatives .so as to get a good motion daily, 
hut no true purgation. .Vlcoholic drinks, meat in excess, iron 
pre]>arations are useless and often harmful. Uaths, in particular 
alkaline ones, friction with horse hair gloves and general massage, 
in short, anything that stimulates the circulation is indicated. A 
point whicli should never he rejectcNl is to endeavor to iliminish 
the pressure on the uterus and consequently it is necessary to 
pro-scribe corsets which constrict llie waist and forw the abdom- 
inal contents toward the pelvis. On the contrai-}' advise the use 
of a lielt or corset which strongly elevates the lower pelvis. .\ 
Uiermal cure will certainly do nuicli good, Neris and Luxeuil 
are useful for nervous patients; the fonner of the.se is specially 
good for lliose patients in whom nervous erethismuK is exci-ssivc 
and the latter for those in whom a nervous condition is combined 
witli gastrointestinal troubles such as cnlero-colitis; on the 
contrary, if the general troubles of nutrition are marked, recom- 
mend Vichy, Royat, Chatel-Guyon, Vittel. 

All these agents are vcrj" suite<l to cases that are plainly 
sclerosis of the uterus. One can in the hemorrhagic forms add 
to it local treatment and in particular dilatation of the uterus. 
The oju'rations to profluce atro]>hy. subvaginat amputation and 
above all supravaginal amputation of the cervix, render useful 
service in advaneerl ca.ses. In more particularly rebellious ca.ses, 
with great uterine enlargement as also in cjtM's of alteration of the 
mesometrium united with arteriosclerosis, this treatment may be 
able to check it, and the necessity of a more .serious intervention 
may lie iiecessjiry to prevent complication and particularly 
hemorrhage. It is for such i-a.ses that complete deslrucliiHi of the 
mucous membrane by intrauterine vaporization has Iwen recom- 




s 

i 



TREATMENT OF INFI-^MMATORY LESIONS OP THE UTERUS 

mcmled; IiyslcnTtomy with a Ijetl^r lechnic and more certain 
results appears to us to be jireft-rable; we have reeoiirse to it in 
the eireuinstanees. 

Let lis add in conclusion that in whatever form of melrilis 
we are dealinf; with, it is always essential to treat l!ic aecoinpumj 
ing le»unnt. To do this, operations, sometimes complex, stteh as 
curettinn. ampntnlion of the cervix. coIporrhn])liy [H-rincnrrhnphy 
and hysteropexy, may lie carried out at the same operation, and is 
the only means of procuring a definite cure, as a treatment which 
is directed solely against the inflammator)- would only give a 
tempDraiT amelioration. 

S. Treatment of Inflammation of the Adneza. 

Tlie treatment of inflammation nf the adnexa has [Missrd 
through very varied stages. I'p to the a])pearance of antisepsis 
lesions of llie adnexa, the |>alhoh>gy of which was little known, 
belonged to tlie domain of medicine. Gradually intervention 
was carried out in certain perinlerinc collections appearing during 
tlie course of tlic puerpcriura. 

The fact that one could antiseplically open the peritoneal 
cavity williout danger, changed the face of the situation and 
almost all lesions of the adnexa ap]jeared to justify extirpation. 
Tait was one of the jinitagonists of this radical surgery; he did 
not hesitate in a unilateral adnexitis to remove tlie tube and 
ovary of tlie healthy side, believing that later its infection was 
almost inevitable. 

It is useless to recall the discussions which arose in extra- 
medicat circles over the incontestable abuse of removal of the 
adnexa. These discussions have lost tonlay their primary 
bitterness, while time shows that more and more, by a sort 
of reaction, the tendency of surgeons is to practice in the most 
extensive measure possible, conservative operations. In iJie last 
few years theo- has Iiecn a movement in Germany against 
all operative treatment, even against conservative operations, fl 
Amann, who, in 18fl», operated 24 per cent, of women with in- 
flammation of the adnexa, in 1901 did only \.5 per cent, and 
considers the o])eration as indicated in lesions of a tuberculous 
nature. A certain number of pynecologists have rallied to this 



I 



t 

I 




TRKATMKNT OF INFLAMMATION OP THE ADNEXA 



423 



view, to a certain extent. Treub had already expressed (lie 
same opinion. 

In America and in France, on the contrary, the operation is 
still the order of the day. 

We will study tJie treatment of inflammation of the adnesa 
in the acute and chronic .stale. 



I. Acute Adnexitis. 



The 



iflai 



iti 



if the adi 



lultinj; 



treatment of acute nmammatuin ot tlie ailncxa. pi 
aside .tuppuration. is of the simplest. 'J'he alarming manifesta- 
tions at the commencement are in relation to the peritoneal 
retention which accompanies acute salpinj^itis. Ajtain these 
infiammatonr' peri-adnexal foci have generally a natural ten- 
dency to spontaneous cure. It .suffices to aid nature In her cure. 
In slight cases, rest in bed combined with hot vaginal injections 
and daily evacuations of the liowel.s by enemas or mild laxatives, 
a low diet is sufficient treatment. If there is acute pain, the con- 
stant application of ice to the alwiomen, and sometimes analgesics, 
Hni indicutfd. 

Generally the trouble slowly disappears, the patient get.s well 
or is left with it chronic inflainmatinn of the adnexa. Exeej>tion- 
ally general Iroulilcs become worse, the fever and ]»ain increase, 
and a punilent (■ollection forms in the neighborhood of the ulerns. 
The surgcim should then intervene and incise the collwtion on 
the most accessible, either by colpotoniy, which is generally 
employed, or sometimes by an Iliac incision. The choice be- 
tween the vaginal route and tlie iliac route is subordinate*! to 
the results obtained by the physical examiualiou. 



h 



11. Chronic Adnexitis. 

In the treatment of chronic a<lnc\itis, the first question which 
occurs to us is: when should we adopt medical treatment, and 
when, on the contrary, .should the surgeon intervene ? 

If the clinical hislorj* of the dis*'a.sc (former brief allacks of 
pelvic peritonitis, pains, fever, etc.) and llie physical examination 
(lai^- fixed mass) makes one sus]>ect the existence of su]>])nraling 
lesion there should )>e no [H>ssiblc hesitation; we must operate. 





4^4 TicE..l.nr5.57 05 LSSl^XMXTO&X 1£^*j9B Off THE riEBUS 

If fii^fTf: I* ai/ifibiteW no «t^>p<xratn« (esonu we should wait 
atA zry rn^^rai treatment. A ccrtam anmbo' of objections 
have ^J*wn nria<i** to the •rnnjerratief tn^dmewt: tbe long duration, 
th«^ 'l^^n^i^r of aft«f attarks. and the aoraber of faihires. These 
mti'i^iri.-* hare f)*«» a little exazgerated. Etwt time, practi- 
fAV\y. that x^ do not think that «~e are dealing with a suppurative 
\*r^l'm. «e advise mtdi*^ treatment. 

'JTie fja-ie of this treatment i» the combinatiiMi <rf rest in bed 
an/] hot vaifirial inje«rtion5. Best is tbe fapdamental principle. 
Ft d'jes not rr*n-iat of half resting, bat of complete. abscJute rest 
in \if-'\ or on a ^ofa. The employment of half measures, as for 
f-xample in alloninz the patient non-fatiguing occupation. 




Fl«. 35*i.— Pincu^' apparatus. 

hIioiiIiI (h; absolutely condemned. The question is, can the 
jiaticiit carry out this treatment .- Hot injections of say 48 to 50° 
i'.. and till! ap(>liration of moist heat to the abdomen and warm 
baths, cither .salt or alkaline, constitutes the treatment in addi- 
tion to n'st. It has also l)een advised to use very hot enemas, 
which act like vaginal injections and give as good results. One 
slioiild pay attention naturally to the regularity of the digestive 
fiiiir'tioris iuid tr> treat the general state by appropriate means. 

A I'crlahi nniiilicr of (iernian gynecologists .state they get good 
rcsulls by vii^iniil packing, and pa.ssing hot air into it. 



TREATMENT OF INFLAMMATION OF TIIK ADNEXA 



425 



Treatment l>y this |«u'king is derived from the old rohimiiiza- 
tion of the vagina and the methodical latnponing bv which one 
tries to secure a sustained pressure on the diseased parts. One 
of the be-st means of doinj; this is with Pineus' a]>])aratiis. 
The patient is placed on the table with the [lelvis and lower limbs 
raised (see Fig. 359). Then insert into the vagina aTi in<iia- 
rubber bulb resembling the Gariel pessar)'. This bulb is united 
by a rubl>cr tube to an eUi])lical glass rccejitacle, which has three 
lubes and three corresponding balls. One communicates dircclly 
with the air, the second with an insufflator, and the third willi a 
second india-rubber ball full of luercurj' (I'ig. 358). By elevat- 
ing this last, one gently s<|ucezes 500 grams of mercury into the 
vaginal bulb, gradually increa-sing tlie weight, but never going 
beyond 1SU0 to 1500 grams. 

This compression is left for one, two or three hours or longer. 




Fill. 359.— 1'cchnic of raitiiiBl pAcldog. 

We shoidd never a)>ruptly bring tlic compres.<iion to an end, so as 
to avoid peU-ic congestion "in vacuo." Now wc employ the 
insufflator. .As the vaginal bulb of mercur\' is emptied by low- 
ering the whole apparatus, air is injected, and finally the tap is 
opened toallow the air to escape gradually in its turn (Fig. 359), 

At the same time an external com]>n'.ssion is made on tlic 
alxlomen with a weight of 5.500 grams of shot. 

The heating of the abdomen helps the absorption of exu- 
dates. This is carried out with a kind of hot-air apparatus which 

flnem {L), Btlfieiungiilai/eruni/, Wiefibadtai, 1005. 



426 THEATMEST OF INFLAMMATORY LESIONS OF THE UTERUS 

encloses the whole of the abdomen, and the heat is generated by 
elcclric lamps,' gas heaters or alcnliol lamps. In order to j>er- 
mit the hot air l« act not only externally on llu- abdomen, but 
also by the vagina, a tubular s{>erulum is inserted whit-h ron- 
siats of practically a mm-eimdiirtor of heat (woimI or hardened 
rubber). 

The air enters the apparatus al a tem[»erature of 100° or 140°. 
The sittings which last 15 minutes at the beginning are |>r(^res- 
sively prolonged to three-quarters of an hour. The skin i.s 
dripping; tlie jiarts of tlu- Imdy in Ihe apj>aratus re-sembh* a 
boiled crayfisli, and an abundant di-scharge occurs by the cervix. 
It is a<Ivantageous during the .sitting ti> pla(% a eonipreMi lioaked 
in fresh water on the foreliead. 

The patient should only have a sensation of pricking; if she 
complain of burns, we must immediately lower the tem|>erature by 
turning olT the source of heat. -As soon as the "seance" is 
finislicd. dry the patient and Wrap Ihe abdomen in hot wool. 
and cover her with woollen blankets so as to retain as long as 
possible tlic lieat. In short, we siibslilute an intense heat iitid 
congestion of the abdomen for the old cataplasm, 

SliouUl we in adnexitis try to act on the lesions liy an intra- 
uterine treatment ? This method has warm partisans and 
obstinate adversaries, (ieiierallv, it consists of dilatations 
followed later by tamponing, euit'ttJigc, or by euthclerizing the 
tubes. It has even been said that a pyosalpinx might be evac- 
uated "per vias naturales. " Anatomical and anatomo-jtatholog- 
ical data scarcely permit us to I>elieve in this and it is held that 
only suppurating iiitralul>al collections sliould Ik* removed. 
There ai-e cases where intrauterine treatment causes inipi-ove- 
ment; the endometritis reacts indirectly on tlie adnexal lesion.s. 
There are those cases in which the lumefaction is not properly 
speaking formed by the inflamed adncxa, but consists of |>eri- 
loncal or periuterine exudates Mliieh proclaim tliemselves clin- 
ically by a <nfruse puffiness of the foinices without one being 
able to discern a well defined, limited tumor. For patients with 



' Pokno, Eine neue Mellioile Apt UobnuiiluoE clironiiicbwi Bccki-iK?Xflti<ltit«. Centr.. 
lil.f. Gun,. IMiitiB. 1901. p. S.IT. ot Ziir .'XnwciiilinK Aur lU-ii^UiUhftapie in drr nynako- 
luRit!. (bidem, 1!HI2, p. OiSl, K«i)in.'r, Bpitr, tat Bi^ltHiidluiiic «hr<mi«ehen Beck<?Wx»u. 
daU>. Ibidem, 1901, \t. 1400. Juiig. Ucilr. x, Ht'iB»lufUK.-mpk' ln-i I<ciokeu<.-il<.-iungcn. 
iluneh. mat. Woch.. 1110,5, p. 2521. 



^^^■pTrKatment of inflammation of thr adnhxa T!^ 

Inions of this kind, uterine dilatation followed by prolonged drain- 
age of lhe<'avity is iiidirated; follovvinii; i)n this drainage, one may 
sec the uterus jjradually lose its congestion, return to its former 
state and the periuterine lesions gmduully retrogress. 

Quite recently. Aulhorn stated he got good results even in 
pyosalpinx. With a syringe holding 2 1/2 c.c, and a flat, 
slightly curved cannula provided with several lateral orifices, 
he injects with moderate pressure into the uterine cavity. The 
lic|uid used Hlmiild lie bactencidut. s|)ecially aiiligonococeic. and 
at the same time should not come into contact with llie perito- 
neum, as nitrate tif silver would cause a sevcrt* irritation. The 
liquid used should be argenlaniiiie (a solution of phosphate of 
silver in some ethylic diamine) in a 2 per cent, solution. 

At first one should inject only 1 1/2 c.c. of the .solution a.s the 
injection causes cramp-like pains; after several injections the 
patient sulTers much less and the whole contents of the syringe 
may be injected with sufficient force to make the liquid pene- 
trate into the tubes. The results were e\'cellent. Kighty-two 
per cent, of the patients were completely relieved of their troubles 
in 4 to .5 weeks.' 

Wliatevcr the treatment employed, even if the tuberculous 
cases are left on one side and where operation is always required, 
surgical inlervention is nevertheless indicated when a grave ctm- 
dition threatens life, or when acute attacks follow on a chronic 
lesion, or when conservative methods have failed, and there is no 
change in objective or subjective symptoms. We sliould also 
take into account the social condition of the patient and the life 
she leads. Also in spile of rninierous attempts. carried out latterly. 
to enlarge the domain of non-operative treatment, we believe 
that in a great number of cases one will be oblige<l to have recourse 
to the removal of diseased organs. When the necessity of n 
bilateral removal is indicated, we should remove the uterus at the 
same time as it is useless to preserve it and it may lead to various 
discharges. 

Tlie oijeralion is not. however, necessarily destructive and 
the surgeon should endeavor to jjreserve all or [Mirt of the dis- 
easeti adnexa in a certain number of cases. We have seen how 



' AuUiorn, Pie nohftnilliniK vntxuDcllipJior Adnvxrrkrftnkungra mit iDtm-itl^'riiMa 
lll)eotion«n. Arch./. «yn., Ilerlin, llllll, T. ,\C, |> 'iili. 




428 TREATMENT OF INFLAMMATORY LESIONS OF THE UTERUS 

a certain number of conservative operations is at our disposition 
(simple freeing of adhesions, followed or not followed by salpingo- 
pexy, expression of the tubes, salpingostomy, ignipuncture, and 
partial resection of the ovary) , 

These different conservative operations may give success, 
and pregnancies may develop later; but the number of these is 
not as great as one would think a priori. If they are frequent 
after freeing of the adnexa, ignipunctures and partial restrictions 
of the ovary, they are exceptional after salpingostomy. 

Also in obliterations of the infundibulum we are tempted to 
systematically remove the diseased organ and remove, at the 
same time, the uterus if there are bilateral lesions. The preser- 
vation of the uterus has no object and has only drawbacks; it 
leaves in the abdomen a bleeding surface, a cornu often infected, 
and a deviated organ; the enlarged uterus is diseased and the 
origin of various discharges, of a sensation of bearing down, and 
of pelvic uneasiness ; its preservation is only a cause of complica- 
tions and trouble. 

Latterly following Beuttner's example, we have combined 
the removal of the pyosalpinx with a wedge from the uterus and 
conservation of one or two ovaries. The early results have been 
very good; but our observations are still too recent in order to 
allow us to formulate a definite opinion on the value of the 
procedure. 



CHAJ»TEU II. 

TREATMENT OF NEOPLASMS OF THE UTERUS AND ADNEXA. 

Simmiflry. — Uterine fibromata (general indications of treatment: Treat, 
palliativp. mnlicnl, ttiirgieal; Trent, radicttl, vaginal and abdominal myo- 
mectomy, hvsterertoray, x-agiiial and abdominal) .^Fibroma la and preg- 
nanrics. — Molignaiit Inmont nf tbe nterns (nitreonm eatiuer, Tn-at, radical 
and palliative). — Cancer of cervix and pregnancy. — Tumors of the ovarj'. 

1. Treatment of Uterine Fibromata. 

Uterine filircimata (flbrous bodies, niyomas, fit>roii)yonia,s, etc.) 
are tumors whose slruclure resembles that of uterine tissue. 
They are benign n(!<»[>Iasni.s. in this sense that in <'ontrM(li.stinetion 
to cancer. Iliey do not become generalized and are not propagated 
to the glands. They arc, however, tuiuon; for wln'eli an o|>eration 
is often enough indicated on account of the complications they 
produce, even in the absence of any secondan,- degeneration. 
The complications are various: some are. so to speak, directly 
in connection with (he Bbroma, such as hemorrhages, which so 
fret]uently acconifmny them, and which arc almost constant, 
when the tumor projects into the uterine cavity. Others are the 
Conse(|nencc of secondary' inflannnaton.' lesions, and particidarly 
tliose of the adnexa ; finally others result simply from the 
pn^rcssive growtli of the tumor, its enormous .size and the 
interference it causes to the intra-abdominal organs. 

These considerations explain to us why certain fibromas 
should be operated and why ulliers should be abandoned to 
themselves. Some partisans of intervention in all cases invoke 
to aid their ideas the t>enign character of early operation, the 
possible sarcomatous transformation of the tumor, and llie 
extreme gravity of a late hysterectomy. It Is certain that hesita- 
tion formerly was carried to an extreme, and tliat it is a mistake 
to await the menopause at any price, reckoning with retrogressive 
influence on the niyomas. 1'he operation is often necessary, 
even when menstruation has ceased. 

429 





430 



TRfUTMENT OF XEOPIA8MS OF THE UTERUS 



But between these exnf^eratcd opinions there is a happy 
medium. To-day the majority of surgeons, while regurtiing 
oijcrutiori a.s indicated in the majority of eaM-s, think that ntation- 
ar}' Bbromata unaccompanied by hemorrhages, pain, compres- 
sion plienonieiia, may be .sul)mitled to a purely jwlliativc treatment 
while being carefully watched so as to be always ready to inter- 
vene in any eftse wliere a change In the evolution of the tumor 
occurs. 

I. Palliative Treatment. 



Palliative Medical Treatmenl.—A series of agents have Iwon 
advocated for the purpose of avoiding operation. Rest in bed 
during hemorrhage, leaving off a too tight corset, u.se of a hypo^ 
gastric belt and hot vaginal injections of 48° to 50* C have in 
turn Ijcen reconuncnded to lessen congestion of the jk-Ivis and 
all have their use. 

There are also certain drugs. Fluid extract of hydrastis 
canadensis. 25 drops two or three tJuu-s a ilay: viliurnum pruni- 
folium. piscidia erythrina, hamumelis. virginica. stypticine. iodi- 
pine, salypirine. and aI>ove all ergot, the systematic employ of 
^^hich was suggested by Ilildebrandt. 

Ergotine may be given l)y month or rectum. Cjcnerally it i» 
prescribed as a hypodermic injection. 

Pozzi advises the following j)rcscription: 



I 



^. Ergotine. 

Chloral hydra!., 
Aqua destill.. 



gmms v 
gmms j 
gi-ains c. 



Inject daily 13 drops of this solution. The injections should 
|}c done with all the indispensable aseptic precautton.s. either into 
llic nmscles of tlie buttock or shoulder. We can thus obtain an 
action on the hemorrhage, and no complications of intoxication 
are oWrved, but [mins and abscesses are frequent enough. 
Tn'atnient is long and painful, and gives hardly any cures. 



TREATMENT OF UTEllINE FIBKuMATA 



431 



Cliloridc of soda mineral waters (Sal ies-do- Beam. Briscous- 
Biarritz. Snlins du Jum, Kreuznach, etc.) have an action wliicli is 
sometimes rt>al on hemorrhages, and they have tlie advantage of 
stimulating the general nutrition. 

Eleetrieity has played tVir sonic twenty years an exiiggerateil 
role, as a result of Aposloli's work. It aj>j)ears to art in intersti- 
tial filironias, which still participate in the life of the uterus. It 
acts essentially on hemorrhages, and also on the pain : 'tis influence 
on the size of tumors is less certain. If we adrl that its action is 
not always harmless, as one would at first he led to believe, und 
tiiat patients have died as result from peritonitis, perforation of 
the rectum and Madder, it will l>e understood why we have 
resen'ed its application and that we have had recourse to it oidy 
in tlio.se women who were rehellious to all o])erative treatment, 
toward tlie approaeli of the menopause and afflicted with inter- 
stitial fihromatji of fair volume which are mainly troublesome 
owing to tlie hemorrhages and pain they cause. 

Latterly we have had recourse lo X-rays to destroy the ovaries 
and tlius bring alxmt an artificial menopause. Kronig obtained 
amenorrhea in 60 per cent, of cases and oligomenorrhea in 30 
per cent. The indications for intervention for hemorrhagic 
myomas may i>e thus limited, as we may have recourse to X-ray 
tri'atnient in palients who an- blanched with loss of blood, or in 
any fat patients or in those witli bronchial catarrh. In a word, 
in all those where operation imlicates a particular gravity. We 
certainly, by these means, seciire a reduction in the results of the 
mortality of radical intervention, as we exclude the gravest cases 
from operation.' 

Palliative Surgical Treatment. — A inimlM-r of surgical means 
have bwn l>rought ftirward to avoid the radi<'at operation and 
have been successively advise<l: hemostatic dilalalion of the 
cervix, intrauterine cun-ttage and can teri nation, utniocausis 
atroph}'ing ligatures, ovarian castration, and jiressing back into 
the abdomen a tumor enchwcd in the pelvis, and pr<Hlneing 
compression complications. AU these means were tried when 
surgical intervention in fibromas was a serious affair. They have 
no reason for existence to-day. If recourse to operation is 

' KrfiiiiK ct (inuiu, Wie wi'it wlrrJ duroh IlAntgvnlx'hniiilluiiK "'xu^i*" oppnttifc 
Tlierspip Iwi Ul«ru8 bliitungnn und Mnitnon l>c«inflii>IT Muntti. mrd. Woeh., 1910, 
p. 1629. 




433 



TRF.ATMENT OF NKOPLASMS OF THE UTERUS 



imperative, do the radical operation, which is hardly more 
scriutis thun operation of niiiiiniul apjicarance, and in atldition 
it is a curative operation. 



II. Radical Treatment. 

As uterine fibroids are so various the operations are also. 

For poIyj)S which project into the vaginal cavity, vaginal 
poh/pcctnmy is the operation of choice. 

If llic ni>roid simply projects into llic uterine cavity, we should 
do a Irarutvagino-uterine myomcclomif after first doing a pix'lioj- 
inarir' hysterotomy. 

In all these cases there is no discussion on the choice of pro- 
cedure. For other varielies of fibromas, however, opinions 
diller; .some desire tlie conservative intraperitoneal myomectomy, 
while others of the radical school cannot agree and either do 
vatjinal hysterectomy or abdominal hysterectomy. 

Abdominal Myomectomy. — .'Vfter opening of the abdomen, if 
we finil a .siiiglr liinior pt-dieuIntLNl, uiyoiuecloniy is tlie o[>eration 
of choice. It is even ad\'ised to do this in single tumors which are 
sessile, but projecting markedly from the external .surface of the 
uterus. 

If it is neces-sary to have recourse to it for interstitial fibroids, 
and al>ove all for multiple fibroids. Martin, in Germany, Kelly, 
in .'Vmerica, and Tufficr, in France, advocate this operation. Il 
i.s very teuipting to confine the operation to incision of the ca|>- 
sule of the fibromas and to their enucleation ; it is the conservative 
tri'atmcnt, par oxcellen(H'. The patient contiruies her men- 
struation and may have children. Of 109 operations Temoin' 
hasoksen'cd five pregnancies come to a favorable cimclusion ; Engs- 
slromin ISOcaseshad nine pregnancies. But these are particularly 
fortunate results. Wiuter- collecled 129 remote ca-scs of myomec- 
tomy, and found only three pregnancies and of these three one 
ended in an abortion at the third month. Schauta only had one 
single pregnancy in 39 eases. Graf in 30 myomectomies only had 

■ Cited l>y 'fullior oDit de Kouville. RcpoH to Uie XV. CaoKrfa internaciorw) ■!« 
mMccinr. Linhonoc. KiDti. 

' Wiiii«r. IKe wUwaBabkrtlichen GounHlnRcn fiir oonMrratlven HyoBWOvnitioa . 
ZtiUdir.f. (lib. «. Oyn., StuttgttTt, IDd-l. T. LI. p- 1U5, 



TREATUENT OF UTEKIKE FIBROMATA 



433 



I 



one pregnancy and wliirli terminato<l in an abortion at the third 
month.' 

The argument thus shown of the ]«».s.siliility of consecutive 
pregnancies while it still has a certain value, has less than one 
would a priori suppose. 

On the oilier hand, while the mortality has diminished since 
1890, when Martin had IK ileaths in 1)6 operations, tlie average 
mortality of ahdominul niyomeelomy is considerably hif^lier than 
that of other operations for myomas. According to Winter, 
it is ahout 44 for 4.51 operations or 0.8 per cent. It i.s true that 
we fiint more favorable statistics, as Temoin had only five deaths 
in 109 operations or 4.1 j>er cent. 

It seems to us that as practically established that myomec- 
tomy which is only appli<'ablf to fibroids that an- easily removed 
having no adhesions, and without lesions uf ttie adnexa has an 
incontestably more serious prognosis than hysterectomy. 

IF we add that many women complain after this operation 
of persistent trouble, of inability lo work, and seeing that one 
cannot l>c sure of removing all the nodules, also that somftinies 
we have recurrences necessitating a second operation, it will be 
understood that its indications are relatively limiteil; e.g., a 
young woman desirous of having children, and having only one 
or at least a small number of myomas and without any inHam- 
matorj- lesions of tlic adnexa. 

Vaginal Hysterectomy. — Vaginal hysterectomy, which has 
been api>lied by Scgond lo large tumors reaching up as high 
as the undjilicus, has gradually had its domain rcslnele<l by 
abdominal hysterectomy. Personally we have hardly ever used 
it. In its favor its lessened gravity has been advocated: that is 
wrong, llie mortality of the abdominal ojwralion in small or 
medium-sized fibroids is to-day almost nil. That which raises 
the mortality of the abdominal operation is that the o|»eration 
is the only one ap[)licable to the enormous tumors often accom- 
panied by renal lesions or cardiac degeneration tumors which 
even tlie most ardent |)artisans of the %'agiual route are forced 
to remove by the abdomen. Cven burdened with these bad 

' Rroii] Hraf, Zur Triin' ilcr konmtrvativcn Myomoponttioaon. Zriuehr. f. GA. u. 
Osfn- 8tutt(t.iri. UlOti, T. Lvi, \>. loa. 
m 




434 



TIUCATMENT OF NE()PI.AJ*MS OF THE l"TERl*8 




cases it is eortaiii that abdominal hysterectomy is preferable to 
vaginal. 

We will prove this by taking the statistics of llie most ar<lenl 
advocates of vuf^inal hysterccloiiiy in France : 

Scf^ond, fid cases. 7 deaths. 

Houiily. 109 cases, 8 deaths. 

Uichelot. 139 cases, 5 deaths. 

Total, 314 cases. 20 deaths, or a mortality of 6.36 per cent, 
and our abdominal operations ^ivo a mean mortality of -4.1 {>cr 
cent., that is. II deaths in 'i&S cases. 

Vaginal hysterectomy is still imlicatc<i for mcdkim-sizi'd or 
small tumors, situated low down in women with an excess of 
adipose tissue on the abdominal wall and having at the same 
time a large vagina and a dilated or easily dilatable vulva. 

Abdominal Hysterectomy. — .\bdoininal liystere«'loniy is indi- 
cated in llie immense majonty of myomas. The only (|uestion 
which presents itself is, if il is better to have recourse lo a total 
or subtotal operation. One of the arguments in favor of lotul 
is the possibility of a cancer developing secondarily in the cen'ix 
left [Hrhind. Botzimy has gatheiiK] togellier :27 cases; it is fair 
to add that after total hysterectomy secondary cancers of the 
vagina have already been published. 

.\gain, total hysterectomy is certainly more serious than suit- 
total; it is about 6.6 per cent, in 499 cases for the total and i.6l 
percent, in IH eases of subtotal, according to the statistics of 
Botzony. The subtotal removal we consider is the o|M*ralion of 
choice aii<t we only do the total in tli(»se ca,si's where the ei' 
is chronically iuHanied. In a general way, it is admitted 
the |>n>servation of one or both ovaries is n.'teful as preveiiti 
the complications of the artificially induccil menopause. 



4 



i. Fibroids and Pregnancy. 



It is difficult to give precisely the in<licutions for treatment 
in eases of myonuis eoniplieating pregnancy, as there is little 
agreement on the subject of the reeiproeal influence of myomas 
and pregnan<>]^'. 

lliere is still a subject of di.scussion, the influence of myoinu| 
on conception, on the evolution of pregnancy and its termination. 



rvix ^ 
that fl 

i 

ni>Tit ' 




FIBROIDS AND PRKOXANCY 



435 



While Ilofmeier. I*iimr<! and others <Io not ivgiinl niyomns 
us iwirig a cause- of sterilily. tJIshauson fimLs that 30 per wiit. 
of women with fibroids are sterile, and Winckel finds 41.0 per 
cent. The eoincidem* of filiroids and sterility appears iinilcni- 
able but we are not tempted to accept Piiiard'3 opinion that a 
Woman has a myoma lieeause the uterus has not fiitfilled itii 
function of f^estnlion. 

0]>inions differ even cm the action of fibroids on the evolution 
of pregnancy. Janiain, in his thesis, inspired by Phiard, writes 
that fibroids in the great majority of cases do not hinder pregnancy 
in any way.' 

And while Pinard found ^0 abortions or nuscarriages in S4 
prrf^naiicies in fibromatous uteri, .\ntnn (>arkis<-h found 86 
abortions in 23*^ pregnancies." 

Till- same lack of agreement from the point of view of pres- 
entation wlien the pregnancy arrives at term. 

P. C. =^90 per cent. (Pinard); .14 (Olshau.sen);. 51 (I^four): 
P. S. =7.8 per cent. (Pinard) ; 24 (Olshauscn) ; 34 (Lefour). 
P. Tr. =0.9 [K-r cent. (l*inard) ; 19 (Olshausen) ; 17 (Lefour); 

On a single point the opinions agree: the relative fre(|nency 
of the faulty insertion i>f the placenta. 

In presence of the divergences of opinion, it can Im' undcrstoml 
tliat the indications of operative intervention have been very 
variously regarded. It appears that accord tends to limit the 
domain of the operation and in a general way the operation 
should be rejected. 

While when there are serious (-'onij>lieations. such as hemor- 
rhage, torsion of the j)e(Jlcle, elc, or when the tumor develops 
rapidly, or if there is acute pain, the surgeon is authorized to 
intervene. 

If it is possible to do a myonieclomy without opening the 
uterine cavity, it would be done in the hope of seeing the preg- 
nancy continue its evtilulion. Hut, if the myomas are hig and 
developed in the inferior segment of the uterus or projecting 
into the ulerine cavity, a radical operation is necessar)'. If the 

■ Jsmain, Ulvrinp FlbroMf nii'l PucniprnKty. Tit. de Pari*. 0. Stunlwil, 1SU6- 
190J. Xo 37. See d!Houll>li<>l1^ uf Uic S«n(t4 il'nliviHritiiie tl« Ryn<eoIogl« et d« pMio- 
trlc. PkHh, leOO, and of thn .Xmiricnn nyii«ooh>ipCftl Soeicljr of lBu3. 

■ Anton (inrkUch, Klin, nnrl anaum. Untr. t. Lthre v. (/WrMmyum, Hnrlin, 1010. 



a: ^ 



43fi 



TREATMENT OF NEOPLASMS OF THE UTERUS 



fetus 1ms not reached the age of viability we should have recourse 
to hystereclomy. 

K the fetus is viable, the operation of choice appears to us 
to be Cesarean section, followed immediately by hysterectomy. 

Ijcaving out coinplicalions, should one in all cases await 
labor and proceed to the accouchement per t'ias naturalesi' In 
order to give an idea of that which this line of conduct leads to 
vre have Pinard's statistics published by Janiain in 158 cases: 

In 1.58 women, we find 23 infants dead before, or iliiring, or 
immediately after confinement, one confinement at five months, 
two at seven months, five at eight months, three at eight and one- 
half months. +1 (hiring the ninth month and 15 near term ; 08 only 
reached full term. Fibroids have therefore an unfortunate influ- 
ence on the normal develojiinent of llic fetus; it would be still 
greater if only the really grave cases were taken into considera- 
tion, because in these statistics figure a large number of cases 
where there was only a medium-sized or small fibroid. develo{>ed 
in the body of the uterus and not H]>pearing to interfere with the 
development of the uterus and labor. Also we believe that dis- 
tinctions should be made Iwtween eases. For the non-encapsu- 
lated we shouhl await term and seek to obtain expulsion per i^i'ajt 
nnliiralefi; in the presence of fibroids developer! in Ihe inferior 
segment, above all in cases of multiple tumors, we do not hesitate 
to operate before labor, doing first a Cesarean section followed 
by b}'$terectomy. In the hands of an experieneeil surgeon the 
operation seems hardly more risky than Ihe total of immediate 
risks and those resulting from a seeondarv renuival of fibroi(t.H, 
and the chances of having a living child are perhaps greater. 

After accouchement, a rapl<l intervention is only imiieated if 
there are complications of gangrene, suppuration, or septicemia. 
Wiih the exception of these cases, one should always wait until 
the end of the periiid of involution of the uterus before making 
a decision, reflecting well on the operative indications as in ordi- 
nary eases quite a[tart from any modification due to pregnancy. 



3. Malignant Tumors of the Uterus. 



The recognized existence of a sarcoma of the uterus constitutes 
an indication of immediate total removal of the organ. I^iis 




MALIGNANT Tl'MORS OF THE TTERUS 



487 



operation should ^ve real cures. G«ssner in his statistics of 
61 cases gives the following results: 

Twenty-six sarcomas of tlie mucous membrane, ten recur- 
rences, five at the end of two, three, five, six and seven niontlis, 
four after one year, one after two years; 16 have been under 
observstion and are well, four after one to two years, five after 
two to three years, one after three years, one after five years, 
two after six years, three after four years, one after five years, 
two after seven years ttiui two aftiT eleven years. 

Thirty-five sarcomas of the wall, 14 recurrences between one 
month antl four years, 31 patients have been seen again without 
recurrence; 11 after two vears. two after three vears, three after 
four years, one after five years, two after seven years and two 
after nine vears. 

The radical operation of cancer nj the uterus gives even more 
lenj»thy cures, as wc have already mentioned iu dealinj( with 
abdominal coJpohystereclomy. 

Wc may therefore conclude that the treatment of malignant 
tumors of the uterus is essentially operative and that if a total 
removal of inva<led parts could he carrie<l «»ut it should always 
be done. We will not return to the indications of the so-called 
radical operation as we have gone into them very thoroughly 
under the heading of abdominal hyslerectoviy and we will deal 
only iiere with canci that juatijij a pnlliattv Irt'otment. 

Some g)'necologists' advisetl vaginal hystercctmny for cancers 
which having gone beyond the limit of indications for the radical 
operation are not nevertheless too advanced (D. de Ott. Bouilly). 
The removal of the uterus would suppress hemorrhages and dis- 
charges ; the recurrence taking jilacc above the dome of the vagina 
would result in a long interval of lime elapsing before ulceration 
occurred. Formerly we followed Uiis practice; the results we 
obtained did not appear to us to be superior to those of simple 
curettage. We have also rapidly a)»andoned this operation, 
which gives an early and serious prognosis. 

The best of palliatives is curcUage, which is followed by igneous 
cauterization. It is the treatment "par excellence" for hemor- 
rhages and ichorous discharges, which are .so annoying to the 
patient. Curettage is also done as ctunpletely as |MissiI>lc and 

' See J. R^camier, I'Tvulnient ol Inopemlile CVuiccr. Pari*, O. Stwofaeil, IflOS. 



438 



f(dlowcd by an energetic eautcrization with the Iherinocaiitery. 
This is successively [mssed over the whole extent uf H\v envity;) 
the floating Heliris of the cervix are excised and the cavity madej 
smooth. Fiiiidly we finish the uperutiori by making an extensive' 
lavage with siil>limate solution, dr}-ing the part and tun)|H>ning 
witli simple or iudororni ganze. 

The results are excellent and the mortttlily nil. It is astonish- 1 
ing to .see how the [KirLs heal and cnrcHage may in certain cases 
be repeated several times with advantage during the course of] 
the disease. 

Its use is well established in cancer with consecutive pyomeira 
following, combined oftenest with cancers of the isthmus, where 
the intrauterine secretions do not discliargt^ well on aci'ount of j 
the blocking up of the inferior portion due to the inlraeervieul 
tumor which obliterates the <'anal of the wrvix. This eonipti- 
cation only disappears when a large o[)eniug permits of regular 
evacuation and lavage of the tilcriiie cavity. Fever and expulsive- 
like pains, intermittent discharges of pus. and sometimes of gas 
ceaM; when a tunnel has l>een made l»ringing freely into communi- 
cation the interior of the uterus and the vagina. 

Chemical cauterization witli chloride of zinc, carbide of 
calcium, etc., ap|>ear to us to be inferior to curettage; their 
application is often very painful and it is impossible to limit 
their action. 

For nodular epitheliomas of the cervix quite iiio[>erable anil 
with bleeding cancerous vegetation sometimes non-ulceraled, 
methylene blue, 3 to 1000 (Mosetig-MoorholT) has Ihm!u recom- 
mended. It is given as an injection, .\bsoltite alcohol injec- 
tions (Sehuitz) arc also recommended. These injections ap]>ear 
to act by bringing almut a necrosis of certain points of the 
tumor and in bringitig about a formation of fibrous ti.ssue at its 
periphery, which retards the growth of the neoplasm. We have 
no experience of these forms of Ireatmcnt, as we always prefer 
conoidal amputation of the cervix with a thermocautery. 

Atrophying ligatures with which we have cxperimenled have 
only given a verj- teni])orary arrest of the secretions ami we 
cannot n-commend them. The application of X-rays and above 
all radium therupy often bring about a su[>erficial cicatrix, but 



MALIGNANT TUMORS 01 



430 



lielow Uie lesions progress nnd Ilit- vi*ry .stiiall aincluinilion Is in 
short less tlijiii lliiit wliicli follnws (■iiivtta«;e. 



I 
I 



I 



With ih 



exceplion of curettage, followeti l»y igneous cauteri- 
zations, we can onlv rceoniiiiemi as local treatment the em- 
ployment of antiseptic injections (potass, perniang., hvflrngen 
peroxide, and l^Hbarnupte's litjueur) and vaginal dressings. 
The latter are particularly useful if we have to deal with repeated 
hemorrhages; simple indofurni laiu)>uns sufTicc to stop them. 

If the nco|>litsnk has invaded the rectum, if a large fistula 
exists Willi an incessant disrhargc of matter from the vagina or 
if the raneerons vegetations in the intestine interfere with its 
evacuation we may i-elieve the patient liy doing an Ular co/(m- 
tomy. Panchct did successfully a bilateral shutting oiT of the 
intestine in a woman whose ileum had a fistula at a point where 
a recurrence had (icciirrcd secondary to a vaginal hyslcrectoniy. 
In all these eases of secondary invasion of the intestine it is the 
intestinal lesion which demands intervention, and treatment 
should he carried out as if no uterine cancer existed. 

When the bladder is invaded and a vesico-vaginal fistula is 
formed the continuous discharge of urine leads rapidly l« very 
painful erythema, and if one is not careful to a slough of the 
.•Mcriini. There is no operative treatment to advocate; it is belter 
to make the patient lie on a rubber mattress which is perforated 
and to wash out the vagina repeatedly with a solution of bicar- 
bonate of soda in 1 to lUUU or I to .>UUO so as to diminish the 
irritation caused by the |)assage of urine and to pacify the |>ain- 
ful erj'thema. The free application of i5 per cent, zinc oxide 
ointment to the skin in order to ])rolect it is of .ser\'ice and 
cystitis and sloughs arc treated in the usual way. 

Toward the end tlie treatment will be limited to supporting 
the patienl'.s strength, easint) her pain and sometimes to inter- 
vene for anuria which follows on compression of the ureters. 
Section of the posterior nerve roots has also liecn adviscil to <piell 
intoleral>Ie pain. This is carried out at the level of the lumbar 
enlargement .so as to anesthetize the lower limbs, buttocks ami 
pelvis {J. L. Faure), separation of the rectum with section of the 
presacral sympathetic branches tJiiiwulay), distention of the fila- 
ments of this sacral ])lexus by injection of artificial serum iK-tween 
the pasterior surface of the rectum and the anterior surface of 




440 



TBEATMENT OF NEOPLASMS OF THE UTERUS 



the SAcniin. and finuDy ann-rectal dilutalion which acts indirccuy 
OD the uterine pain (I'oncet). 

To tliis (ipcrattvi- trentnu-nt of [wiiri wo prefer the simple use 
of narcotics, in particuhir subcutaneous injections of niorphin or 
of heroin, which wc must not hesitate to give in .sufficient doses lo 
produce sleep. Suppositories of extract of thebaine and anti- 
pyrin cachets also render .service. K[)idural injections, the lech- 
nie of which is much more complicated, do not appear superior 
from the point of view of results. 

The slow uremia characterized by oliguria, gaslric trouhlcs, 
changes in the temperament improve after giving saline purga- 
tiv<^, oily enemns. suticutaneous injections of artificial scrum, 
caffeine, pilocarpine and milk diet. 

To combat early anuria due to coraprejtsion of the ureters, 
various operations have been done such as lumbar uretero-, 
neostomy (I^- Dentu), nephrostomy (I^geii, Chavannax, 
Poncct, Jayle). It must be understood that this anuria is often 
remittent and that after several days, untler the influence of diu- 
retics and injcclioiis of scrum, the secretion has rca]>p('ared and 
the slate of the patient improved. We hardly ever advise these 
operations, which are often useless and which in case of success 
only lead to a prolongation of a miserable life. 



i 



4. Uterine Cancer and Pregnancy. 

In ])resenpc of a titerinc cancer complicated by pregnancy' the 
therapeutic indications are governed by the degree of operabiJity 
of the mother and the state of viiiljidt'/ of the fetus. 

The first question that apjjeai-s is: Is the cancer operable or 
non-operable ? 

Operable Cancer.— The evolution of cancer, during pr^nancy. 
is extremely rapid and we shouhl not he.sitate about a decision; 
it would result prolmbly in .<iacrificiug the Ufe of the motlicr, while 
conser\ing limited chances of saving the infant. 

Diiritiij tin- f\r.i( four months the o|>eration is that of vaginal 
hyslerectomy. The uterus is drawn down lo the vulva verv* 
easily because of the relaxation of its suspensory ajipamtus 

' Cullcn. CwKwr of tho UWn», N. Y., 1900. Oui. Ann- dt gyn.. PwU. 1W7, p. 193. 
EATi-e}-, Uandb. d. (lyn. dt Veit, WlMbftdtn, 1890, T. Ill, iroonif porl, f>. 480. 




UTERINE CANCER AND PRBOSANCY 



441 



rollowing on (iregnancy. The utcru!), generally, may lie taken 
oul en bloc with its contents. At the fifth or seventh month total 
alMlominal hysterectomy has heen dune, supravaginal amputation 
being followed by estirj»alion of the cer\ix by the vagina (Zweifel), 
and the abortion having ))een excited is foHowcd l)y vaginal hys- 
terectomy once the involution is effected. To-day the general 
tendency is in tfiis case, to do a vaginal liystcrectomy, splitting 
the uterus once the cervix is liberated from the vagina and the 
parametrium, and afterward proceeding to the extraction of the 
fetus and fuiishing as usual. It is about the eighth month that 
the question of the child occurs. We must bring forth a living 
child and do a radical operation fur tlie mother. We <]o then u 
Cesarean operation followed by a total hysterectomy in the 
usual way. 

At the time uf accoucliemnil we cannot hope for a sufficient 
dilatation of the cervix if the cancer is limiled as the invaded 
jjarts are incapable of extension. 

If, on the contrary, the cancer is extensive we may do a 
Cesarean section and then hysterectomy. 

Immediately after th.e accouchement and without awaiting the 
involution of the uterus we do a vaginal hysterectomy, the dila- 
tation of the vag;ina renders the operation very easy and the 
uterus may \h- drawn down as far as one likes. 

In spite of the rapidity of evolution of the cancer in the 
gravid uterus, these operations have shown some survivals. 
Olsbausen, who did i5 vaginal hysterectomies with 25 successes, 
had up to the time of publication of his article, followed nine 
patients during a fairly long interval and of these one died after 
six months; four of them bad recurrences after five, six and one- 
half, seven months and three and one-half years, res|icctively ; 
four were well after two and one-half years, five and three- 
fourths years, six and onishalf years, and seven and one-half 
years respectively. 

Inoperable Cancer. — ^If the cancer is inoperable, the child is 
the first consideration. We confine ourselves to a symptomatic 
treatment. If the mother dies and the child is viable, we may 
do an immediate Cesarean section. At term, as soon as labor has 
commenced, do a curettage of the cancerous vegetations, make 
a star-shape<l incision in the ccr^-ix antl extract the child cither 



I 



U-2 



TREATMENT OF NEOPLASMS OF THE UTERES 



vvilh forct'iiH or hy version. The fetul tnortality is seven tlciilhs 
in ^9 cases or about i5 per cent. In reality it is oonsideraljly 
higher, -since lo tliese iO cases we shoiiht in reality add 10 in 
which perforation was earned out. so that wc see iJint extraction 
per viaH naturttfcx gives in reality a mortality of 43.57 i>er cent. 
It appears preferable to do Cesarean section, which is followed 
by I'orro's operation, being careful not to cut the uterus too near 
the cancer, because of the inflannnatory infiltnilion of uterine 
tissue which exi.tls in its neighborhood. This procedure is less 
gnive than the conservative Cesarean operation, which in cases 
of cancer is often followed by septic complications. The fetal 
morlalily is considerable, about 47 per tTnt. ; it is, however, less 
than that of extraction pet vias naturalrs; the results would I»e 
still U'ttor if the operation had not been often practice*] too 
late, when the child had already succumbed during tlie courjie 
of a jjrolongi-d labor (Oiii). 

5, Tumors of the Ovary. 

During the opening [leriod of abdominal surgery operations" 
were limited to llic removal of evst.s of the ovar\- when bv (heir 
large size tliey seemed likely lo injure the general health. In 
1883 Spencer Wells declared that it would be Ijetter lo remove 
ovarian tumors us soon as they were diugnosiii. T(Miay the rule 
is fixed: every omrian tumor Uftien ditit/nose/i should be removed 
immediately. 

The operation when done at the commencement is less grave 
and places the patient in a i>osiliori of ae()iiiring nunierou.H com- 
plications such as inflammation and rupture of the cyst and 
torsion of its pedicle. Finally niidigiuint ilegeneration may 
occur, as in 058 eases of cysts remove<l by Schroder, \W) wen- 
degenerated. 

Malignancy of tumors docs not constitute contraindication to 
intervention. 

While sjH-aking of this, we should make s[H>cial mention of 
)>apillary cysts, the removal of which when they are accom- 
|Minied by ascites and peritoneal grafts, may be follower] by a 
recurrence so late, 5. 10 and iH years after, as almost lo constitute 
a cure (Pozzi).' 

• Poiii, Rev. lU gvn. tl de Ckir. abd., Patw. 1904, p. 407, 



TUMORS OF THE OVARY AXD PRKOKANCY 



443 



I 



Ls no conlrairHlication; cures have tjeen brought about in 
infants of one year and old people past 80. 

Thf only <iucsti<Mi disc-ussi-d is that of knowing if in the case 
of finding a unilateral ovarian tumor, one .should remove the 
ovarN' of the oppositi^ .sjile.' This opinion is supported by a 
certain number of g_vnecologists. Personally we remove the 
healthy ovary whenever thi.s organ lia.s cea.s4'<I its functions; on 
the eonlrar)', in young women we always keep the healthy oi^^ans, 
these that in a certain nviniber of ca.ses we have seen pregnancies 
develop to the jireat joy of our former operated iMitients. 

6. Tumors of the Ovary and Pregnancy. 

Audebert has collected 241 ovariotomies done during preg- 
nancy and finds five deaths or i.X j»cr cent; in 79 per cent, of 
cases the pregnancy went on to full development." It is clearly 
seen that any ovarian tumor diagnosed during jiregnancy shoiUd 
be o[)crale<l on. I.s there any object in waiting until the sixth or 
seventli month so as to increase the chaiiees of viability of the 
fetus? \\V ilo not agree with lliis and think with Po/zi that all 
a tardy intervention causes is a new rtsk to both mother and 
infant. The indication is to operate as soon &a tlie diagnosis 
is made. 

We take certain precautions during the course of the interven- 
tion. We make an inci.sion long enough to easily extract the cysl, 
the volume of which has lieen already reduced by puncture, gently 
draw the tunit»r laitwurd and avoid traction on its j)edicle. After 
the operation, as Pinard does, we give systematic injections 
of morphia in order to prevent the production of uterine con- 
tractions. 

Inuring labor we should only intervene if the tumor by reason 
of its pelvic site j»revents the engaging and expulsion of the fetus. 
We sliould try to press it I>ack with our fingers which are intro- 
duced into the rretum, avoiding the while too violent pres- 
sure wliich may rupture a cystic loeulus. In case of failure 
ojH'U the abdomen and remove the tumor, ami if tliis is im- 
possible do Cesarean section. 

■ D. V. VirliU. Uelior <lii< Daucrcrfolji^ dcr Ovnriotomie, Ardt-tiir Om., BiTlln, ISCM, 
T. LXXI.X. p. 333. 

• AmJobi^rl . Siir rf"o6»/,. gun. cJ pfd . Purit, Oot. 10, l«4. 



CHAPTER 111. 

DISPLACEMENT OF THE UTERUS. 

Siunmary. — Tn'«liiient iif fcenilnl jiroliipsc. — Moans of fixation of llw 
ulonis. — ^AnnUiroo-palhological lesions of prolapsc-.^Fwiplij-larlic trendncnl; 
iiicdicHllTratnii-rit (initsAiigr, pi-.^snrir.^, inj<-i-t!c>ns uf paraffin antl quininr). 
— Opt-mtiw Ireatmcnt. — 'rmitmcnt of vaginal cnlerocele. — TreAtment of 
uterine deviations fc)tiiggtTrtt<'<l inoliility. aiilt'tlfxton. rrtrodcvialion. wlro- 
flcxion of the gravid litems). — Utcriuc inversion (puerperal and |>uly|><iid). 

In this cimptcr we will successively study the treatment of 
prolapse and that of deviations. 



1. Treatment of Genital Prolapse. 

Before beginning the study of the therapeutics of genital 
prolu])se it appears to us to be of advantage to recall in Iwo 
words the disposition of the means of fixation of the uterus and 
vagina. This short aimtoinical glance will enable us to Wtter 
grasp the pathogeny of prolapse and of exposing in a rational 
manner the indications of tlieir treatment. 

The |>elvic organs in a woman are maintained in their normal 
position by various agents, tliusc of suspension and otJiers of 
support. 

Principal among the suspensinn agents we find the peritoneal 
joUh which run from tlie uterus to Uie walls of the ])clvic cavity, 
broad ligaments, round ligaments, and utero-sacral ligaments. 
If these ligameiitii were only formed of peritoneal folds they 
would count for ver)' little. Ueiiiforced as they are by fibrous 
or muKcular tisxue derived from t!ie uterus (round ligaments, 
utero-iuieral ligaments, and ligaments which run from the border 
of the uterine cervix to the pubis, taking their course external to 
the vcsieo-pubie ligaments which they reinforce), they constitute 
but feeble means of fixation and are practically only small cords 
of moderate tension. Uelow is the sheath of the uterine artery 

* 

and llie sacro-reclo-gviiilal aponeurosis. It is agreed to-day, as 

444 



tm:atmf.nt of genital proi^psk 



445 



FBralkoiif statpt], that both arc only ni)]»cM»lages of a porivascnlar 
fibrous formation which is very unequal in its development, and 
included with the inlra-pelvic bmnchcs of the internal iliac is 
called the hypogastric sheath. Its role is more manifestly seen 
along the borders of the vagina, where it is a resistant sheath 
accompanying the vi-ssels and {-4iii.slitutiiig the most ethcacious 
means of fixation of this canal. 



^^^ 




Pia. 360. — MwDH of suHpenuoii of and UgamcnU of the uterua (»fter Farabcuf.) 



The means of support are disposed about several planes 
arising from the perineum. 

We first notice the perineal body, which is constituted esseu- 
lialty l)y llie anterior segment of the anal sphincter, the 
transversalis superlicialiji and the constrictor of the vulva. 

Initnediately below is a sort of diaphragm, partly fibrous and 
partly mnseidar, which s]>nngs from (he [mbic arc^h behind the 
ischio-cavernous muscles and is inserted into the vagina behind 



-4 h. 



446 



DlSPLAl'KMKXT OV TUK UTERI'S 



and IjilPi'iiIly into a jmint corresjioiuling to the hymen. AnU- 
riorly tins (iiapliruj^iu is less well dovelopfd and is eiisily jkt- 
forated by the finger on the line with the ni-etiira. 

Deeper aiileriurly we find the [iuh*»- vesical ligaments coming 
off from the internal face of (he pubis, laterally and poslertorly 
the fibers of the levators which ginl the vagina laterally and 
proceed toward the preanal fold, then to the sides of the anus 
and tlien behind the anus, thus eonstilnting an infundibniiform 
diaphragm on which the pelvic viscera lie, 

'riicse various means nf fixation have an unequal importance 
and the seetiuii of the means of suspension facilitates niuc-h less 
the descent of the uterus than ^-ulvo-vaginal splitting. The 
facility. ho%vcver. with which one draws the cervix t<» the vulva 
after this operation is a current observation of all gj'necologists. 

One is forceil to admit that in genitjtl [irolajiKc the ]>rimordial 
lesion is represented by the insufficiency of the perineum. In fact, 
this perineal iusiiHiciency is never at fiitilt without being in direct 
relation with a tear of the perineum. Torn perineim>s are seen 
t|uite often, where the tear extends to the anus without the least 
descent of the genital organs. The tear favors ]irola[>se but does 
not produce it; it i.s necessary at the same time that there exist an 
insufficiency of the su]»])orting power of the levators and general 
degeneration of the fibrous tissues of the pelvis. 

In practice several cases may present lliemselves. Sometimes 
there exists an evident tear dating back to a more or less recent 
confinement and involving the perineal body to a greater or le«s 
extent. Sometimes insufficiency is of oljstetrical origin, but the 
perineal region is intact in appearance. The nius<'uhir appa< 
ratus is none tlie less gravely damaged; it is a question in these 
cases of subcutaneous tears of the muscles and the palpation of 
the perineum shows it to be relaxed, thlniu'd and ritUieed to a 
plane of integument. This atrophy of the muscles of the peri- 
neum is indejMMulrnt of all traumatism; we have to deal with 
patients whose muscular system is degenerated and whose 
abdominal wall is enfeeble*] and whit besides their genital 
prolapse, suffer from ptoses, renal and intestinal, and hernias, etc. 

Whatever else may l>e the cause the insufficiency of the 
perineum o{>eiis the dimr to prolapse. The vagina shows a 
progressive eversion through the gaping vulva. (Jenerally there 



I 

I 

1 




TREATMENT OF OKNITAI. I'ROLAPSE 



U7 



is at first prolapse of the anterior vaginal wall, an anterior 
coljKH-ele, then of the posterior vaginal iviiH. p<».sUTior ool|HM'fIe. 
Anterior colpoccle is always accompanied by cj'stocele. by reason 
of the anittomica) Rolidarity of the vciiical ami vaginal walls. 
On the conli'ary. the posterior colpocele generally exists without 
an accompanying reetoc-ele. 'i'lie vagina in unfolding U'conies 
larger and assumes manifestly exaggerated diineusions. At the 




Fio. 301. — Means of support of ihfl uU>ru>. BpIow thi> miil'tlc anom-urnri* kre 
the muscltw which by ihnir conviTneiicf jni to (oriii (.ll<^ pi-riiioal body; piisMriurljr 
the fiben uf ilie li'vutor art- sw-n lo i-mtrgfiroin its pusiFiiur fiio«. 



same time the irterus becomes progressively lower and ap|)ears 
at the vulva and in extreme cases may issue in its entirely exter- 
nally, dragging with it the vagina. It goes without saying thai 
such an extreme relaxation of all the ligaments enters into Iht'se 
cases. 

The falling down of the uterus does not form the only lesion 
of this organ. Excepting metritis and particularly cervical 
metritis, which is rarely absent, there exists a much more char- 
acteristic lesion: hy[MTlr<)phy of the cervix, esiM-cially of the 
supravaginal portion, which was described by Huguier a long 



^V DISPI^C£MENT OF THE ITTERVS ^l^^^l 

time ago, but which he was wrong in attributing u^ the primary 
cause of prolapse. 

I Tlie more the iilenis falls ilowii thr more it is tilted down and 
backward, by reason of the cervix being drawn anteriorly and 
inferiorly under the traction of the anterior vaginal wall. 

latterly, Marion and his pupil Ilousseaux liuve insisted on 
the in)|M>rtancc of the abdominal depth, primary, congenital or 
secondary to a prolapse of the uterus or of the [M>uch of Douglas.' 

As may be seen, the lesions of prolapse are multiple and are 
most often eonihim-d; it is illogical to (lisas.sociatc them from the 
therapeutic aspect even when they appear to be diiTerenliated. 
This isolation is only apparent and a clinical examination will 
always show the complexity of the lesions. 

'i'hesr few pathogenic ideas permit us to approach the study 
of the different modes of treatment proposed for genital prolapse.^ 

I ProphyUctic and Medical Treatment. 

Projtiit/lactic treatment (hws n()t !i])pear to have a great im[>or- 
lance. It has been pointed out how important it is to refKiir 
perineal tears and to favor uterine involution, so that the parts re- 
assume their volume and tonicitv. It is well to recommend to 
young women after labor to remain in l>e<l three weeks so as to 
avoid premature fatigue, household efl'orts and to wear an abdom- 
inal l>elt. Hut we repeat we must not have any illusions alwut 
Ihe^c prophylactic means. 

Medical trentmenf relieves in a certain degree, but does not 
cure. Il is evident that in cases of pnilapse which have remainwJ 
a long time exposed, and become ulcerated, nietho<lical reduc- 
tion, commencing with the parts nearest the vulva, following by 
antiseptic dres»ings, ivnders great service. 

It is a necessary treatment Ijefore commencing operative 
intervention. 

The genu-peetoral position, the cohimning of the vagina. 
an<l Ihe use of astringent injections have iH'en advocated. Their 
efficaciousness is doubtful. 

■ RouMMUx. TrcAinieiit of Ci-rtain Coam of Uteriii« Prolnpw by the ObliUralion of 
tifpoadi of DQ<i|tl». Th. lit Pari*. )DOS~ieog, No. T. 

'W« will Imw on nnp nilr tlw- imntmant of prolftiiM sympUnutio ol ft lumor of 
til* iit«ru« Mid iu iwlnvxn; l)ic prolapM, beiDi; only » nct^ondMy lerimii. b «ur«d 
Ml Kmoral <A tho iirimnn- uusc. \i%. de nenvpoot, Leu prnUpBut g^niuax *yinp- 
tom>Uquci>. Th. if fanV l(K)a-04. No. All.) 



PROPHYLACTIC AND MKDICAL TRFATMENT 



449 



MaBMgt, consisting princi[>ally in movemenU of elevation 
of the uterus, combined with SwetJish gj-innjislics, have given 
succe.vs. 

Pessaries may for a time relieve the patient, but ihey do 
not hinder the prof^ress of the ilisease; their size continnHlly 
aujfments and finally the pessary cannot be borne any lonj:;er, 
which condition is prodnetHl by ulcerationi? or juiinN or what is 
most frequent, it will no longer remain in place and becomes 
useless. The pejwary is in truth only useful where there is a 
rcsistnnt floor. In other cases the simple pessary i.s iusufficienl 
and if for special reasons, one is induced to have recourse to 
this iiislruinent of contention, use pessaries with a stem wliich 
protrudes between the legs and is supported by a sort of T-ban- 
dage (hystertiphore). 

We should also mention as intermediate in the meilieal 
treatment aii<l the operations, the injwHons of [wratHn the 
whole length of the vaginal walls, much praised by Pankow, 
Douglas and \Y. Stone,' and the injections of quinine as Inglis 
Parsons' does. He injects into the Ihisc of the broad ligaments 
in the hofte of provoking a curative sclerosis of the [Miramctriuni. 

In short, wc cannot <'ount nnieh on medical treatment. It 
is important to leave it on one side in the immense majority of 
cases. It may be cmployeij when Ihc patient formally refuses 
intervention and for any reason whatever when the operation 
is contraindicaled. We would then have recourse to i>essaries or 
hysterophores if the pessaries an' fountl to be insufficient. 



Operative Treatment. 

perative treatment should always be pnK«dcd by a careful 
examination of the patient: this will enable him to immediately 
distinguish a vutjiiial herniit from prolapse which may have a 
pedicle or not and has special operative indications. 

The operations for gcnitid ]>rolapsc are ven.' numerous. 

Some are done by the abdomen and their object is to render 
firmer the suspensory ligaments, etc., of the various parts con- 
stituting the prolapse. Some nurgeonit devote tlieir attention to 

■ Doittlba nikd Stone, Brii. Uid. Jotinutl, 1903, T. II. p. 79. 
' Initlla ParMDO, Confri» inirm. J44 »t. Wriic., Pariii, IWU. 
3» 



i 



460 



DISPLACEMKNT OF THK UTERUS 



the bladder, the displacement of which is generally ver}' marked in 
genitiil prolapsf, and have carried out cystopexy. Others fix the 
vnjjina above. The majority seek (o act on the uterus either by 
drawing on it indirec^lly by the shortened muiul ligaments 
alrca<ly dune in the inguinal o])cration. or by shortening the 
ulero-sacral ligaments, by directly fixing them to Ihe anterior 
abdomitud wall according to any one uf the procedures of 
hysteropexy. Some have gone further: they have commence<l 
by u hysterectomy and then fixed the slump cither lo Uie anterior 
al>dominal nail or to the stumps of the broad ligaments (Jacobs. 
Ligamentary tracIielo[H-xy). 

In anotiicr series of cases gynecologists have operated exclu- 
sively from below, t-onfinlng Ihemselves to supporting Ihe uterus 
by cotistricling the vagina. Tliis is done by putting in a series of 
metallic rings under the mucous membrane or by making a 
more or less thick fx'lt, by doing an epLsorraphy. a luirtilioning of 
the vagina, or even a total colpectomy without removal of the 
uterus. 

The remote results of these various operations have in genera! 
Ijeen me<liocre. As we have seen Ihe Ictifms uf genital proiaftae 
arc nmUipie and Uie treuimeut should therefore be complex. 

First, we must diminish the hyjM-rtrophy (eer\-ix and vagina) ; 
second, reccmslitute the insufficient [lerineal sn|»port. not for- 
getting the importiint role of the muscular floor formed by the 
levators; third, to redn-ss tlie ret rode via led uterus. 

These various indications are carried out as folloxvs: 

An am|)Ulation of the cervix, a resi'clioii, more or less exten- 
sive, of the vaginal walls will reduce the hyjwrtrophied parts; 
then the perineum is iveonstilutcNl by any of the proewlurcs 
usually employed, particularly that of splitting with suture of 
the levators;' the operation is terminated if there is any retro- 
deviation by an indirect hysteropexy. This gives to Ihe uterus 
an inclination almost perpendicular to thai of the vagina, sU)>- 
pres!i<>s the tendency of Ihe uterus to invaginate and thus increases 
the chances of a definite cure. 

I lyslerectuniy is indicated only if there exisiA a concomitant 

' It hrna l)«cn kdvunl In (wh'i of bcmik of the pouch of DouKlikH during lli« »]>litling 
epacMloBto open Ui« pcritoaral ouI^ituMc wid ni imrtUlly »U|>pr«Mti^ it- (Krsnk. 
FVewiil, StnU). 



PROPHYLACTIC AND MEDICAL TRRATHKNT 



451 



gnive lesion of the uterus; It is then m*ce.ssary not to confine 
oneself to tlie removal of the organ and to combine with it a 
plastic perineo-vaginal operation. 

Outside inveterate prolapse when the vagina is entirely 
invaginated. hyperlrophied, and ulcerated, we must do a pre- 
liminary treatment to reduce the prolapse and to apply anti- 
septic applications and keep the patient in l>ed. IIy{>eremia, 
edema and pseud o-hypertru]>hies disappear so well that the 
operation becomes simpler. 

In rebellious ea.ses with a com]>)ele tear of the lis.sues wc 
are sometimes obliged to do a simple palliative treatment of a 
medical nature. 

Treatment of Vaginil Enterocel«. 

VagitKit mterocelc forms in the sj»ace Ijetween the uterus and 
rectum: stopped below by the perineum it presses against the 
vagina and pushes \\s posterior wall anteriorly (A. Cooper). 
Sometimes it is a simple exaggeration of Uie pouch of Douglas, 
which may project into the vagina and even out of the vidva; 
sometimes it is a pediculated tumor of the posterior wall of the 
vagina; in fact, a real hernia.' 

\Mien we are dealing with a j>e4iiculuted hernia, tlie moist 
rational treatment is the free o]>ening of the sae, its excision al 
the level of the neck, the resection of tlie cxulwrant parts of 
the vagina and then suture. 

When wf are dealing with a protrusion of all the posterior 
wall of the vagina pressed forward by the intestine which dis- 
tends the abnormally devclnped pouch of Douglas, we would be 
tempted to combine an extensive [jostcrior colporrhaphy with an 
abdominal hysteropexy, followed by obliteration of tiie pouch of 
Douglas by tlie abdominal route. 



2. Treatment of Uterine Deviations. 

Tlic imfwrtanee given to uterine devialtons has been *vci7 
varied. For a long time they were practically unknown ; catarrhs 
and inflainnialor)' engorgementt »ere the two principal condi- 

' Bergpr, Vagimil lkmi»fc C^rt^U franc. 4c Chit., pMi^ 18W, T. X, p. 3*. 




452 



DrSPLACEMENT OF THE UTERUS 



tiniis: tlit-n, foUowin^ on a sort of iractioii. cuiiif a cicsrription of 
the deviations as essential diseases, in particular inflnnimatort* 
slates of the uterus or adnexa. In fact, uterine deviatitms rarely 
^ive place to palholoj^cal trouhle when they exist alone; certain 
dysmenorrheas appear, however, to lie in relation with an exagger- 
ated anteflexion of the uterus; moreover, the deviations may 
eonlribute to keep up or to aggravate inflainmatorj' eonditions 
of the uterus and are tliernselv(>s soineliniL-^ a. eausc of sterility. 
It is. therefore, indicated to treat Ihem. 

XorniJilIy tlie uterus is in a state of slight anteversion with a 
moderate anteflexion. 

This disposition may be exaggerated and anleversions and 
anieflexiuns of a |>atho]ogical order are to l)c seen. Most often 
one has to treat retrodeviations, retroversions or retroflexions. 
Finally there is sunu'tiuies an extreme laxity of the liganieiils and 
the uterus oscillates in the pelvis, sometimes being anteverted and 
sometimes rctroverte<l. 

In all eases we should he careful to find out if there is any 
perineal insufficiency, or metritis or inflammation of the adnexa. 
as these lesions should be tlie object of special tivatment. 



Exaggerated Mobility of the Uterus. 

Among certain women, as we have already said, we some- 
times get anteversion and sometimes retroversion, and most fre- 
quently the latter owing to tlic backward pressure of the inlro- 
abdominnl organs. These women, who complain mainly of reflex 
nervous trouble, neurasthenia, various [miits, {wins during walk- 
ing, have almost always gastric troublesand constipation. If they 
ore examine)! with care, we will find that they have also enlerop- 
losis, a vertical <hslocation of the stomach, movable kidney. 
etc.. etc. 

Order them a belt pressing from lielow u|jwur(I on the hypt>- 
gastric region. If the abdomen is developed or relaxed, a fortiori, 
if there is euteniptosis. we re*-ommend a belt, which must 
accurately fit the projecting iliac spines of thin women. Corsets 
relieving the lower abdomen <ir even U'lts with pneumatic 
cushions, such as lluise of Enriquez, are useful. Finally insert 
a Hodge pessary or one of its derivatives. 




DEVIA1 



4o3 



General treatment to inukc tlic |>atient .stronger and to ciiliii 
her nervous -system should never be neglected. 



Anteflexion. 

I'aUiologic anteflexion may be congenital or acquired. 

Congenital. — It results from an arrest of development and is 
liabitually associated with other malformation states of the 
cervix which i.s conical, stricturrd and oldileratcd at the level of 
the anterior lip and of the vagina, Uie anterior lip of which is 
too short. 

Acquired.— \i is not accompaincd by any deformity of the 
cerWx other than that which may result from a concomitant in- 
flamuuitory slate. 

It is distinguished by dysmenorrhea and by a relative sterility. 

A whole series of operations has licen sii/igesled for it; some 
are destined to act oii the cervix and on the deviation at the 
same time. 'I'he simple dilatation of the uterus with laminaria 
touts suffices generally to markedly ameliorate tJie condition of 
the patient. 

Retrodeviations. 

Retrodeviations arc frequent and arc di-stinguLnhcd by the 
fixation or mobility. 

Many fixed retrodeviations should be seriou.sly con.sidi're(l; 
they belong to a class of lesions which Pozzi calls lesions of cure. 
"lesons de guerison."' With the exception of renewed attacks 
of inflammation, there is hanily any pain. There aw also 
concomitant intianmtatory lesions wliich should be treated. 
The minor means are the following: Hot injections, ma.ssage, 
hydromineral cures, etc., and in case of failure, in women near 
the mcuiipaiise do not hesitate to do a total rastration. In 
younger women be more conservative and att**nd to the cervix, 
curette the body ami re<-onstitute the perineum, and if necessarj' 
do not hesitate to profit by the ancslJiesia to open llie alHlonien 
am) liberate the uterus maintaining it in good position, by using 
any of the various procedures we liave described. 

' Poui, iDdiraliuniiforTrcafrDnnt in RotrodovEtliooK of tlie Vtam*. Bevtit <fe gyn.> 
Pftria. 1807, p. 387. 



454 

Mobile Retrodeviation. — ^The palhoUigiral importance' of 
ihis cundilion has been wrongly denied by several gynecologists. 
Various operations have been densed. snch as hysten)iM-xy, 
ingninal or abdominal ^ihortening of the mnnd ligaments, vagino 
6xatiun, etc. When the retrode\'ialion is associated with 
another lesion, such as perineal insufficiency, lesion of Ihe 
ccn-ix. etc., giving rise to operative intervention, we should treat 
simullaneously the de\-iation bv a surgical opcnition which 
permits of an immediate cure. Wc should be authorized also 




Fio. 363, LidlnH iip of tlie Iwily of ilio utoni* with mi) (ini^n in*ori«il into Ute 
pgalcrior fornix, while the ulfJumiiiiil luiiul (otlon-n the diopliuflniciil <SchultM}. 



to intervene surgically in women who must be curwl rapidly 
lo cam their livelihood. 

If. on the contrary, the woman is in such a condition that 
she can take a prolonged course of treatment, and is not exposed 
to fatigue, immediately the c|ue.stion of orthofjcdic treatment 
arises, ft would .seem that there is a reaction against tlic abuse 
of surgical interventions, which were so widely practised ten 
years ago. 

. Schultzc,' who has always ad\ised orthopedic treatment, 
advises the rcflressing lo be carried out as follows: 

' Itich^lot. W> Must Rodrcw Rotrorcnrioo*. Cong, frane. it* Ckir., Pkris, 1005, 
p. 3(m. 

■ Sdiiiltw. Ziir Thnniilin liartnackig«r Itouodexiun <tur Gcbinnutter. Samml. ttin. 
Vom., 18DI. Ni>. 24. 



TREATMENT Of UTERINE DEVIATIONS 



455 



Tn order to reduce the organ in cases of mobile retrodeviation 
Jie lifts up tile l)ody of the uterus !>_v means of two fingers intro- 
duced into the vagina, or into the rectum, and carrying out this 
manipulation under the constant control of the other hnnd» 
which follows the organ through the abdominnt wall (Fig. Sfi'i). 
When the body of the uterus has been raised as far as the su]M.'nor 
rectus, which is not difficult to do in spite of ])ressure which is 
exerted in the direction of the arrow, the extremities of the fingers 




Fic. 3«3.— AlWr hnviiig pxi'reiaed a prMaure on the wrvlK In the djroetioa ot 
Iho MTow fto AS to h«lp Uie redressing, tbo bund on tlie liypfigaiitrio Itogka tfa* 
fUDdiu of l)i« utt^ruB. 

of the hand on the hypogastrium receive the fundus of the uterus, 
and convey it very gently forward, so as to leave il in it* 
normal position, behind the symphysis. During this time, the 
fingers inserted in the vagina as in figure 804. R-cogni7.e if 
the superior portion of the cervix has preserved its suppleness 
and its normal flexibility. Make certain of the reduction of 
the redressed organ otherwise it will reoccur We now insert 
a |H*ssary. which by putting tension on the posterior fornix of 
the vagina, and pushing it upward, draws the cervix in that 
direction. 

Use a Hodge pessary or better a Schultze, or Smith, or Thonia* 
and never use intniuterine pessaries, which may give rise to 



456 



DlSPLACftHENT OF THE UTERUS 



troiiblp. If a simple vaginal pessar)' is not sufficient to liold tlic 
uterus ill |>laec. il is liccause uf perimetric- adhesions; the surgical 
operation then is indicated. 

Pozzi ill France, and Kustner in Germany,' are (he defenders 
of the l>loo<lless methods. After a biinauual reduction of the 
deviation, they mjiintuiii the uterus with a i>essarj*. This ought 
not to be considered as a simple palliative; it shouhl permit of 
tlie ron.solidation of the means of fixation of the oi^aii. Its 
em|)ioy is ne<;e.s.sarily a more or less U'ngtliy [K-riod, fnjm .some 
months to some years; finally a cure is brought ahout and the 
pessary may be taken out. This orthope<iie treatment would 
give, according to Kustner, results superior to those of o[H'mlive 
I rent men t. 




Flo. 304. — Tli« uUtnii rwlrc^Mtd. thn Hnicrr* in Iho vnt[iiia determine the su]i|il«tMwa 
of Ibo Mupenur jKirliuti ol the c«rvix (tiokulse). 



Retroflexion of the Gravid Uterus. 

Hetroflpxion often redresses itself during the course of preg- 
nancy; but this is not constant and when the deviation persists 
towanl the fourtli month, complications in the bladder occur, 
which abandoned lead to a retention of urine and to that grave 
form of gangrenous cystitis, so well studied in France by I'inard 
and Variiier.' 

■ KilstDcr, llandb. d. Oyn. df Veil., 1907, T. I. p. 133. 

'1'jiiar.l uul Vnmier. Anit. <f< jyn., Ptav. 18WJ. T. II. p. 338; 18S», T. 1, pp. 85 
KUtl 33S. 



I 



TREATMENT Ol" UTERINE DEVIATIONS -167 

There is then absolute necessity of reducing the deviation at 
this moment. In general it i.s very easy, and in all cases vvc 
have ol)serve<l we have been able to do it by simply pusliing 
back the fundus of the uterus into position with the extremities 
of the two fiiigfrs enguj^etl in the vaf^inn. and making it pass 
from I»elow upward along the concavity of the sacrum. It is 
important not to act on the angle of flexion, but to commence 
the reduction by acting upon the most posterior portion of the 
fundus of the uterus. The organ having been redre.sscd slays 
in pitiee if (he re<luclion liiis been done towai'd the fourth 
month, al the time when vesical troubles appear. The uterus 
is tlien of such a volume that it cannot fall buck into llie 
peine excavation. 

In exceptional cases, where by reason of adhesions the manual 
reduction is impossible, then one may open the abdomen, break 
down (he adhesions and redress the uterus.' Some g)'necol(»gists 
do an anterior fixation of the organ and insert a pessary. These 
nianij)ulations are only to be thought of if the pregnancy is very 
early; if it is near the b)urtli mouth, they are useless, and wc 
should content oui-selves with simple redressing of the uterus as 
we have already inilicatml when speaking of the manual re<in-ss- 
ing of the uterus when vesical troubles come on. 

Uterine Inversion. 

Uterine inversion may result from a fibrous polyp or follow 
on an accouehemcnt. 

Puerperal Inversion. — Wialever the form or age of the inver- 
sion, the surgeon slionid first of all seek to do the rcdncti()n by 
simple means. If Uie placenta remains adhen-nt to the fundus 
of the inverted uterus, commence by separating it and then 
reduce it. 

This is most often done by manual lariif. Tlie cervix is held 
firmly by forceps in the hands of an assistant, who continues a 
sustained traction. The operator with the left hand presses down 
tlie abdominal wall, and immobilizes the uteru.s; with his right 
hand introduced into the vagina, he conipre.sses the body of the 
uterus, renders it supple, and then endeavors to reduce it, always 

■ FmakeiMtcin. DcvMcJk. nirJ. H'orA.. l^ipiiK, IBIO, i>. KKIH. UaIh. MonalMlir. /. 
GA. und G<,n.. Berlin. igiQ, T. I, p. HS. cSirtofolelU. Oyn. Rvndutau. I»10, p, 44». 




468 



DISFLACBMICNT Of THE UTERI'S 



it liv which re(h]fti 



ih 



endeavoririg tn finil the ])oint tiy which reductum is most easil 
carried out. In jteneral pressure on the fundus is inefficacious. 
and it would Iw better to \tegin wilh the ])arts near the jiedirle. 
Piiiani iiisistji on two points: only to commence taxis after liaving 
pushed the ulenis hack into the vagina : second, only to use trac- 
tion ill the iiilerval between foulraelions, if one performs reduc- 
tion inimeiliately after confinement. 

I Sl<yu} Mfihoih. — Replace the iiiantial acliim l>y a contiiiuouii 
pressure carried out for several days: first, hy tamponing; second, 
hy instruments acting on the fiinihis of the uterus l>y a rigifl stem, 
the pi-cssure lieing administered hy an midniiuahle handage or 
English repositor; third, hy pressure with air and water pessaries, 
Braun's and Champelier's Imgs, which give a certain numlter of 
good results. 

These melliods have the inconvenience of their k'ngthy dura- 
tion and pain tliey cause, the complications which they may cause, 
such as fever and pelvic peritonitis, etc. 

\Miatevcr the |»rocedure employed, once reduction is obtained, 
give a little ergotine and tampon the uterine cavity with itMluforni 
gauze. 

i If one fails or if the uterus appears to lie threatened with 
gangrene, we iimsl do our reduction by a surtjiral operation^ either 
by the abdominal or lieller by the vaginal route. Vaginal hys- 
terectomy is only indicate<l if there are grave hemorrhages which 
threaten life inimediiitely or ii tlie inverted organ presents mani- 
fest signs of gangrene. The old procedures, of removal of the 
inverted portion with a crushing iiistruinent or serri'-na'ud or 
elastic hgature, which were used for the purjjose of destroying the 
orteriejt nnd jH-ritoneum liefore the prola|>.<;c of the organ, have alt 
been abandoned to-day. 

Polypoid Inversion. — 'I"he first indication to fulfill is lo 
remove the myoma. As it is often diHicult to say where the tumor 
exactly ends awl the true tissue of the uterus begins, it i.s well not 
lo do there and then a section close up to what iipjK'ars to be the 
insertion of the polyp. Taking hold of the protruding portion 
of the polyp with force[»s, it is s])lit vertically by ilegrees until 
we reach the deep part of its cortex; nothing is siuijiler then 
than to enucleate it. In a (certain number of cases as soon as 
one has removed the tumor which draws upon the fundus of tlic 




TREATMENT OF UTERINE DEVIATIONS 459 

uterus, it reduces of itself. If not we may proceed to the reduction 
as in puerperal inversion. As in these cases we are generally 
concerned with women of a "certain age," the uterus frequendy 
contains fibrous nodules and thus the indications of the radical 
operation are increased, and we can resolve more easily to do 
vaginal hysterectomy than in puerperal inversion. 



CHAl'TEU IV. 



EXTRAUTERIHE PREGNABCY. 

Sununary. — fJonrrnl mdivalions of trcaiirn'nt of rxlrnut^'rinc |ire);iiiii)C 

e ai cnt]i|>liciilii>iis. 



-T. nf I 



.ll 



; th*- fii>t ti\ 



ith: 



il> 



prfgnniipy 

T. of the peritoiirKl Iirmorrhngf of cncj'stpcl hi-mnloccl'' fithvr intra- or 
siibjicritoiicn). — T, of |tregriiiiirv after the fifth month, oI») fetal cvsls. 

In the course of its evolution rxtniutrrinc pivgnaucy may be 
attended l>y numerous complications. In the printar)' period 
Umt most to be feared is hemorrhage, whieli nmy he veiT ubuii- 
danl. constituting thus II veritJihh^ |)eritoni-itl inundation, placing 
tlie life immedialely in danger or failing that it may lead to the 
formalinn of hemorrhagic collections in ihe pouch of Douglas, 
such as rclrontcrine hcinatocrles, or more exceptionally to sul>- 
peritoueal effusions or intraligauicntary hematoceles. At a more 
advanced p'riod, when she aji[>roaehes terni. the extrauterine 
pregnancy may he the cause of complications. Finally after the 
death of and [Hirtial alisorption of Ihe fetus. Ihe lilhojiedion and 
the sue containing the skeleton may, l»y reason of the dcvelopnienl 
of adhesions, cause abdominal troubles. .\t all periods, therefore. 
infection is possil)le, as the sac may su]»purate and as we have 
seen after long years of silcru'e, u litho]>cdion may inflame, sup- 
purate, and o]>en into Ihe bladder or rectum. 

Also, in presence o{ an extrauterine pregnancy, we must act 
quickly.' 

Fornirrjy. the rlrath of tlic felus was aimc<I at either by modi- 
fying Ihe health of the mother by hunger, by hemorrhages, or 
by adminislralion of sirychnine in slightly toxic doses, or directly 
by the death of the ovum I)y electrical a])plicntions or injections 
of morphia. 

> Runga. Dcdtr x. Aetfol. Sympt. u.Th<*rm]4edtExtmit«riii|nviilMt. ANlu/.Oglt^ 
1903. T. LXX. r»ac. 3, ScBoml, Tmtniciit of Extnntoiliie Pr(||aualea, Cbw. UUM. 
d'obvl., gya. ct p<vl.. ■ccniid iviHioii. Murnrilln, ISflfl, and Svme A gyn- Pmk. 18Q& 

L80I. U. KiiHtncr. L'ebi-r l^xtr»uUTlti>trhw)uiKcr*c)m(t. Saninl. klin. yorirag.. 
(Mis. I8mi. No. 344. 

AW 



4 



I 




PREGNANCIES IN THE I'lRST I-IVE MONTHS 



461 



To-day ils treatment is exclusively surgical. 

Every txtrauterine pregnaticy ichen diaiftiosed sitouhl be 
operated on. Some years have elajised since Martin showed that 
by ex[)cctanl treutnionl we gcil Iti.S per cent, of cures and by 
operation 7(J.7 per cent. We should like to add that if interven- 
tion is early the pcn-cnUige of eiii-es is slill hiijher. Kiistnerin 
107 eases had only two deaths, one of which wns from peritonitis 
in a patient with liei>ati<' cirrhosis, when the n]>eralion hati been 
long and in the other, a woman who was anemic from former hem- 
orrhages which were extremely ahnn<ijinl. Straucli (Moscow) 
operatet) !>l tiilial pregnancies and luul no deaths. 

From the point of Wew of indications to fulfill it is well to 
divide them into those eases lieforc and after five months of 
prt^nancy. 

1. Pregnancies Observed in the Course of the First Five 
Months.^lf there iire no complications, siiiiie gynecologists 
carry out an expectant treatment, holding themselves in readiness 
for tlie least sign of danger. It is a line of ctrndiiet which would 
|)ermit of argument if the ovum were dead or if there had l>een 
an expulsion of a decidual membrane, luit, if the ovum were 
continuing to evolve, it cannot I>e considered seriously for a 
moment. 

Generally, the removal of the gravid tube is doneby thealwloni- 
inal route; in some cases on inteiTention has been essentially 
conservative, and some surgeons have removed successfully a 
tubal mole after incision of the tube, and have afterward sutured 
llie incision, which Ircatinent seems hardly suitable to moles in 
iJiis stage of retrogression.' Total eastralion, advocateii for the 
purpose of put ting an end to all i-ecurrences, appears a contraindi- 
cation lo us.^ We have seen a numln'r of our operate<i eases have 
a series of normal pregnancies after removal of a pregnant lube. 
and hence w<- do not advocate castration unless at the same time 
there is an inflammation of the ailnexa on the op]>osite side, or 
in short, lesions which of themselves demand removal. 

In rare cases of tnlMMntcrstitial pregnancy do a hysterectomy, 
with the intrauterine opening of the sjie by a sound |>assed by the 
dilated cervix (II. Kelly), a practice which will Iw, so we 



• Mnret, Rev. dr oyn., Pftri». 1898, p. 
•Sen*. CriUrftI Slinty u( Eiglitv-mn 
L dt Paru. IliOl. .No. 20L'. 



195. 



nine ObMrv«lioii« ot RMiimnt Ectopic Gwtation, 



462 



EXTRAUTERISE PREGNANCY 



think, little fo!lowe<I. In such a rase we are tempted to doTi' 
wMlge-slia[M-'d excision of the uterus, as well as a i-emoval of the 
lube followed by suture, and when we have to deal uith an inun- 
dation of the perlUmeum, the imtiiediatc o[>cration is iiHlicatcd. 
On this score the danger of shock enters in and possible errors 
of diagnosis. These ol)jeelioiis have no value. With large 
injections of serum, either if occasion requires intravenous, we 
do not fear shock in these eases. As to errors of <liagno.Ms, such 
as intestinal obstruction, torsion of tlic [lediele of a tumor, etc., 
these demand the ininiediale opening of the abdomen and do not 
con train( ilea te oix'ration. 

Expectant treatment gives 86 per cent, of deaths, and opera- 
tion 8.5 per cent, of cures. 

If we have a hematocele the operation is indicated all the 
same. It should bi; done abdominally if there are successive at- 
tacks showinj; that hemostasis is not complete. It is then indi- 
cated not only lo remove clots but to find the bleeding point and 
tie it; then remove the bleeding tube, completely closing the ab- 
domen and leaving, without drainage, the blood which has not 
Ijeen evacuated dnring the operation. In such east's the simple 
vaginal incision which leads lo a continuation of hemorrhage 
shouUI be rejected. 

On the contrary, if the hematocele is well encysted, and 
particularly if it is infecte<i eoljtotomy is indicated. Exceptionally 
in certain cases of pelvic subperitoneal hematocele or inguinal 
hematocele in order to evacuate the seal of trouble, we do an 
ischio-reetal incision (I^'jars), or an inguinal subperitoneal 
incision (Pozzi). The indicalion is always the same, that is, to 
go to the spot wlicr*' the collection points and incise and drain it 

S. Pregnancy After the Fifth Month. -If the fetus has passed 
35 lo 3fi %veek.s. it is %'iable; we nmsl o]>crate immediately without 
waiting false labor, because at that time tlie infant dies rapiilly, 
and the pains use up the mother's strength and place her in a 
less favorable 0[)erative condition. 

If the fetus is living but is not yet inable. opinions are divided. 
Some say that the mother only should l>e thought of and that 
an intervention should be made. This idea is founded on the 
fact that complications may occur and, also that the fctits is 
frequently doometl or If it arrives at term is malformed. Others 




PRRGNANCIES IN THE FIUST FIVK MONTHS 



463 



find tliat there is a real exaggeration in the operative indications. 
nn<l tlmt one should wail, and givr tinu: to thi- fetus to develop, 
and tliat one should exercise a continuous watch over the patient, 
being ready to operate if the least compiieation arises, or if the 
mother bcconiea enfeebled. 

When the operation is decided, we must determine by whot 
route to do the intervention ? Some gynecologists, particularly 
in Germany. o]>erate by the vagina. This route is dangerous 
if the placenta is inserted in tlie pelvw ; the extraction of the infant 
is dangerous and often there is great difficulty in stopping any 
hemorrhage. 

We should operate by the abdomen, open tlic sac at a jioint 
where it is thin, draw out the infant by the feet and tie the cord. 
Then eomes Ihc crux of the tpu'stion. Some operators, fearing a 
prolonged suppuration and hernias following and finding that 
the sac is friable ami diflicult to fix, wish to remove both sac and 
placenta. Others, desirous of avoiding hemorrhages whicli 
sometimes follow immediately after sejiaration of the placenta, 
advocate the nmrsupialization of the sac. and await the spon- 
taneous separation of the placenta. The line of conduct is 
advised by Baudelocque, and supported by Pinard, who had 
Ifi cures in 17 cases. 

We should distinguish l)elween eases. If tin- IVtiis is free 
in the peritoneal cavity, or if during the primary niiinenvers 
there is a partial separation of the placenta and a consequent 
hemorrhage, then removal is necessar)'. If the enucleation 
seems easy and there is no insertion of the intestine on the pla- 
centa, then hcmostasis of the tube or of the ejtiploun is easily 
procured, and removal is a matter of discussion; personally, 
we advise it because it is a means of cutting short the duration 
of the treatment. If tlie placenta is inserted only [mrtially 
into the intestines, we should have no hesitjttion in leaving it. 

If the fetus is dead, indications of an immedialc oj)cration 
present themselves, such as hemorrhage, peritonitis, etc., etc. 
In abs4Mice of complications it is better if the deatli is recent to 
wait some time, as the intercystoplaccnial circulation progres- 
sively diminishes. It is prudent not to wait too long, and to 
operate before six weeks' time l>ecausc of the congestion which 
accompanies a return of menstruation. 



4«4: EXTRAUTERINE PREGNANCY 

[ntervention is often indicated later and we should not wait 
iintil a Uthopedion forms. 

FinailT. if we have to deal with an old fetal cyst, tolerated with- 
• im :inv complications, or having a fortiori suppurated, we should 
■jperate. The fetal cyst should be removed like a cyst anywhere 
•ii*: :he 'suppurating cyst should be opened where it points, and 
^he iitbopedioQ should be taken out and drainage made of the 
:.to*.'ket. 

Iti a sin^e case, the rule that one should open where it points, 

■ lUichE tiot to be followed, and that is when the cyst points in the 
-e«;tuiu; even then, if there is a beginning fistula in the intestine, 
•I is. preferable to do a free posterior colpotomy in such a way as 
'.u liniin it, and to make repeated lavage of the pocket, and thus 
otKiedvor to ^t a cure of the rectal fistula. As to cysts opened 

u :h<- bladUer, they may be very simply cured by simple evacua- 
•um :hrr.«uy:h the dilated urethra, if the fetus has not yet attained 
:ive :tK,»aCbi*: if. on the contrary, the fetus is older than five months, 
V* e "Jt«.»uld be forced to do a more complex intervention, either by 

■ (ic v.'ttvE«.»vesK"al route or the intraperitoneal. 



CHAPTER V. 

MENSTRUATION TROUBLES AND STERILITY. 

Sununary. — Mcnytnuitioii Irmibk-s. — Priiiinn- or se('i>n<l«rv uiiirtmr' 
rh*"*.— Mi'iiiirrliafjin iitnl mctrf>rrh«giii. — Djsmeriorrlifa. — Troubles of llio 
mroopausi?. — Treatmont of sU'rility. 

1. Troubles of Menstruation. 

Under the name of inenstruatioii is understood a dischorfie of 
blood from tlie uterus at certain repular intervals iluring tlie 
iiexual life of woiiiun, wliieli iionuitlly viiries from 13 and 15 to 
45 and 50 years. 

This di.s<'liarfie may not occur, amenorrhea; or may W loo 
abundant, menorrliapia ; or occur with diffieuUy. dysmenorrhea; 
finally its cessation may 1>p aceonipanied by a series of complica- 
tions at the critical period called the menopause. 

I. Amenorrhea. 

.\menorrhea may be jiriinifiiv, as menstruation does not occur 
at (he regular a^i'; it results from a simple rclanl in the eslablish- 
nient of menstruation from an arrest in the development of the 
reproductive organs, or from an atresia, which may occur at 
various points in the fjenital canal, and ]>i-evenling blood from 
issuing exlermdly. In this case it is not strictly sjjeaking amenor- 
rhea, but a menstrual relenlion. 

In presence of a primary amenorrhea the first point is to 
discover if the amenorrhea is due to an arrest of development or 
menstrual retention. An examination of the genital organs in a 
young virgin is always a delicale matter. Wc shoiihl iti the 
absence of menstrual molimen temporize, in the hope that it is 
simply a retard in the apjH-arance of menstruation, (renting the 
anemia if it exist, and make her lead a life in the 0]«-'n air, Ircali*"* 
tlie constipation whieh a<'C(miing to Kelly is always associate 
amenorrhea. If, on the contrary, the young girl sutFcRi 

30 405 




466 



SIKKSTBUATION THOUDLES AND STEBILITV 



ically, there is prohahly a menstrual retention, and we shoiilil 
then do a f^nital examination and treat the h/mencal or vaginal 
imperfonitions as soon as those arc discovered. 

If this examination demonstrates an arrest of devdojjnient 
in the uterus, one is alniinst at a loss to do anylliing. Also, if 
ovarian ]>aiiis are exeessive and nothing ean case them, do an 
ovarian castration. Knowing the action of X-rays on the ovaries, 
we iniglit Ik- teni])led to do some radiotherapy. We do nut know 
if it has already l>een tried, hul it apiiears to us Uiat attempts 
might l*c made. 

If there is no pain, and no trouble hut the ahsenee of menstrua- 
lion, we shoidd content ourselves with a genend li'eatment, so as to 
cause the patient to turn her thouglits from her genital organs. 

Secomhrtf amenorrhea or supprp.>ision of menstruation may 
Iw due to varieil causes. The first idea that the gj-nccologist 
conceives is that of pregnancy, hut after having proved this not 
to Ikt the case we mu.st look for other causes of amenorrhea. 

Cicatricial atresias are exceptional; generally it is due 
to constitutional trtiuhle (chlorasis, tulwrculosis. acute or 
chronic diseases, obesity, etc.) or functional (change of cli- 
mate or regime or nervous exliau.stion, etc.). The treatment 
consists in treating llie cause. Euunenagogues such as rue. 
sabino, apiol, etc.. have not any well demonstrated action. We 
may use saline aiul drastic purgatives, jH'rnianganate of potash, 
electricity (faradic currents, continuous currents, static hath with 
sparks drawn fn)ni the lumbar region). 

With amenorrhea is sometimes associated .lupplementari/ 
menglriiotinn, vicarious or ectopic, a hemorrhagic discharge 
occurring from the nose, stomach, inlestinct etc. 'VhU supjile- 
mentary mcnsturation is sometimes a cause of relief to the patients 
whic-h slioidd Im* n'spccted; exco|)lionally if it becomes .so abun- 
dant as to endanger life, we may be forced to remove the uvurics 
(Welwler, FLschel). 



4 



II. Henorrtiagia and Metrorrtwgia. 

Mvmrrrhagia is only an exaggeration of tlu' normal flow. 
Metrorrhagias are hemorrhages which occur between menstrual 
[H*rio<Is. Sometimes it exists in conni'ction with genend disease 



TROUBLES Of MENSTBDATION 



467 



hy alteralion of the lilood (liemitphilia. .scorl>iilus. jfravp icterus, 
phoetphonis poisoning, cachectic slates, atid the oonimencement 
of certain jiyrexias), an<] most often in eoniiecliuii witJi a local 
lesion connected generally with the uterus demand, and these 
hemorrhages usually an indirect treatment, that of llirir cause. 
We will make a special mention of certain nienorrhagias of the 
young girl, which appear to be mainly of functional origin, ami 
coniliincd with vasomotor troubles brought on l>y a relaxation of 
the tissues following on their rapid development al puberty. 
They demand a general treatment. 

As uterine hemostatics we may recommend repose in bed, 
hot vaginal injection.s at 48° to 50^. ergotine by the stomach or 
sulicutaneoufily,' hydrastis canadensis,' stypticine,' adrenal- 
ine.* choloride of calcium,* electrical applications and vaginal 
or uterine tamponing. 



III. Dysmenorrhea. 

It is very frequent to see women complain of jmin in the (lelvis, 
back, and thighs, and of a slight nervous excitability at the time of 
menstruation. We cannot say that Uiere is dysmenorrhea except 
in cases where the increase in these troubles iM'comes pathological. 
Tile jviins tuay .soinetimcs be sucli that the patients have to lake 
to bed, covered with sweat, the extremities cold and they .some- 
times lose <'onsciousness ; sometimes they have nauwa and 
vomiting. 

It is difficidt to give precise therapeutic indications for the 
treatment of «lysmenorrhea, as the causes of the troubles are 
still verj' in)])erfectly knoAvn. In certain gross lesions (|H'lvic 
inflanunations, myonias, n'troflexions), a <-HUsal Ireatmrnt is 
necessary. Unhappily, in the majority of eases, the cause is not 
precise. Mechanical dysmenorrhea has been described. An 
acute curve in tlie cervical canal, a contraction of one of the ori- 
fices of the cen'ix, a clot or membrane preventing the flow of 

< 8ri|ilp cTKot 10 to 60 Mntlgrkina doily, id pills or cnnhota: Yvon orBOliM, • Mnti- 
meivr euhe iuji-^vd HubouUiieouflly niglii ami moroing. 

' I-'luid<?xtract of bvdnutiii homanirlU. viltuTnum, 10 k^md* of molt ilollx: tmkt 
tbrici.- diiily 2') litMiA o{ thii itolullon iii a Ultlt' wntvr. 

' Four ti) »ix (ul-luls or nipHuIi-H (UJIy fnataitUDR S ntntigrKDU nl ttjrpUoIlM). 

■ tirty tcniiRrnniH to 1 Rrsm nf 1 In 1(N)I] •oliilion milinutanouualy. 

' Four KTftinH diiily in a )jutioii of 150 cm. oubw lu bu taken l»y toupqiOOnruU BVi 
two hours. 



7 



408 



MENSTRUATION TROUBLES AND STERILITY 



hemorrlinge: lliis theoiT in much discussed lo-day. Tha( wliich 
isgifiicrnllv u(iiiiilU><i is llmt in dysnu-norrlica Ihcn- is u spjisiiiodic 
state of the uterus of which Ihe cause is tuificrfectly ktiown. 

When the pains appear give sedatives (phenacetine. pyra- 
midon. chlural. valeriHiiate of atntnoiiia, nulipyrin. etc.). n]iplica- 
tions of hot water bags to the ahdominal wall and mustard baths 
for tlio feet. 

With Ihe exception of menstruation, endeavor to stimulate 
the fteueral state I>y repose, in particular after the midday ineal; 
and by a substantial alimentation, by a calm life in the o[>en air 
and by regular evacuations. 

Uterine dilatation is sometimes useful; euretlagc faihmed 
by applications of iodine, carbolic acid, and fjlycerine, etc.. have 
been advised. KIciss says that applications to certain points of 
the nasal mucous membrane with a strong solution of cocaine 
slops the pains, and has described sexual points in the nose. 
Koliseher hax oblaiui'tl analogous efVeets by Cf>caini/.ing other 
mucous membranes: that of the cervix uteri and rectum, and 
it wouhl seem to be due to suggestion. The ingestion of ovarian 
preparations was advocated by (libbons. 

Jn incural)le cases, do ovariectomy; this is authorized, if the 
continuity of the pains affects the gcnerol state. Slill It is nol 
certain that all these troubles would follow on this mutilation. 



IV. Troubles of the Menopause. 

When the menopause comes anil even more after the artificial 
menopause prmluced by bilateral castration, we sometimes see 
a series of troubles follow, which persist in certain people during 
many years; thcs*- are heat flushings, insomnia, [lain in the liead, 
migraines, a ncuro- muscular or psycluc neurasthenia and some- 
times oljesity. 

Walking in the open air. motor trips, and absence of excessive 
physical excitation and moral emotion, a regime for oliesity, 
and regular action of the intestine constitutes the genemi base 
of Uie Ireatmeul. 

Against the.se heat Hu.<ihings and nocturnal sweatings, wc 
find that hot baths about 40° are often very useful. Ovarian 
o{>otherapy is verj* useful. .\s the ingestion of the raw ovary i.n 



STEHlLITy 



4G0 



verj- oUen repugnnnl to patients, give ovarino, powder of desic- 
cated ovary or ocn-iiie. ilnw) corpora lutea. bn.se4j on tlic idea 
lliat the corpus luteum is the active part of tJie ovary. ^ 

Bv these means we line) a notable amelioration in the state 
of llic [Mttents. 



2. Sterility. 

Tlie nuinljcr of sterile niarriafies is about the same in different 
countries, oscillating lietween 11 and 13 |«?'r lOU. Formerly it 
was customary to ini[)iite the sterility to the woman. Jt is known 
to-day that in 4(f ]>er cent, of cases sterility is dejK--mli-iit on tlie 
husband, exceptionally due to loss of puissance, but {jenerally 
due to azoospermia; tlial in H to 13 per cent, of cases, it results 
indirectlv from the huslKiiid, «hi» lias transmitted gojionOiea to 
his wife, riMHieriiig her sterile, so that in 59 per cent, of cases the 
giiilly [lerson is the husKind (Sanger). We should always think 
of this whenever a woman comes to consult us in order to have 
children. 7'he treatment of sterility in woman kIiouUI never be 
umlertalccn until an exnrninntimt is first made of the husband to 
dettnnine the state of his generative functions. 

Once the slate of the huslwind is found salisfactorj', in order 
lo treat sterility well, find out the cause. 

The history, es]}ecially that dealing mtft tite study of the 
physiofftiomy of menstruation, givi-s us Pinard remarks, important 
information. 

A woman who commenced to menstruate at 12 lo 15 years, 
and whose menslniatiun has always been painful, particularly 
in the first twenty-four hours, has probably a flexed uterus, with 
more or less contraction of the canal. 

A woman who menstruates late, from 16 to 20 years, and 
irregularly, losing little, and complaining of i)ains about the 
ovaries, is a woman wliose ovular evolution is difficult and 
imperfect Often it is a thin woman with heredilarj- antecedents 
fif rheumatism, gout, arthritic troubles, and antecedent persiuiaf 
historj- of urticaria, migraine and herpes, etc. 

A woman who commenced normally to menstruate, but loses 

■ Olve two shwp ovurtca <UUy or 10 lo 3D naticraras ot orarinc oiw-qu]irl«r & 
hour before tnuala. 



^70 



MeXSTRUATIOK TROtTBLES A>'D STEtUUTY 



les:<i and les^ and at longer infervals. is oneii afTeded wttli prrro- 
cious and cxaggeratcsl embonpoint: in such a rase the o\iiJes 
no longer mature. 

In a woman whose menstruation is normal at the commence- 
ment. )>ut which iH-ctmies more frequent and abundant and run- 
tains clots has generally a fibromatous uterus. 

Having put our fjuc^itions «c should proceed lo the 
direct examination with the object of 6nding out if there exiiitx 
an obstniction either preventing the progression of the ovule 
toward the uterus or the ascen.sion of spermatozoa, or a |»8thn|og^ 
icai state of the endometrium preventing the fixation of the 
fertilized ovule. In very exceptional cases we may find that 
the woman is a \irg)n. Vaginal examination combined with pal- 
pation will show us dcfurmilii-s. uterine deviations, and the 
existence of false vaginal routes, etc. The examination with 
a speculum may show a thick opaque or yellowish obstruction 
or cork, as the French exjjress it, on the cer\*ix. 

The results of this examination will give indications of treat- 
ment. 

Metritis, uterine fibromata, uterine deviations, stenosis or 
indanimatory states of the eer^-ix maybe treated in the usual 
way. In uterine flexion, ililatation and redressing witli lami- 
naria tents, followed by dilatation with a catheter and followeil by 
Ilegar's i>ougics renders splendid service. 

If it is a case of imperfect ovulation, Pinard recommends 
an absolute milk r^ime at intervals during one or two months. 
The otK'sity disuj)|>ears, the menstruation l»ecomes normal and 
fecundation stx>n occurs. 

In cases of irregular menstruation, at first small with an 
infantile uterus (enlarged cer\-ix with a ver\- little body), we must 
have {>atience and abstain from all surgical intervention, and be 
content to favor tJic general development of the organism by 
exercise, a suitable hygiene and thermal cures. 

Static electricity often renders service in women where the 
uterus is normal and the menstruation cea.setl suddcrdy. 

'IVniptirary re|Kise for the genital organs, and alkaline vaginal 
injci'liouji aix- us«'ful adjuvants of Ireatment in ncrvouj* women. 



PART V. 

OPERATIONS ON THE URINARY APPARATUS. 

CHAPTER I. 

CHEMICAL EXAMINATION OF THE DRINARY APPARATUS OF 

WOMAN. 

Summary. — Questions, frrquriicv &n<l p&in of micturition. — Examinn* 
lion of urine. — Exnniinutif»n€)f Ihciin-llira (iiii'iitus, Skcno's jjliiriii.t.raiial). — 
Exam illation of the liladder (pcrcuBsion. palpation, rathcterization. cystos- 
rnpyl. — Exarniiinlion of tlip un-li-rs fvii^innl exfltninalion)— Kxatiiiniilioii 
of tlif kitlnej'-t. — Intravesical scjiartttion of tlic urine. Catliclcrizalioii of lite 
ureters. 

1. Interrogation.— If we have to deal with a woman who coiii- 
ptains of iiriimnr' Irouhlcs wc lihotilfl licgiii liy hearing [hv jialictit 
and thi-n <|iieslionin(; Iier. 

1. In<|uire into the utate of mictuntimi, it.s frequency and 
jiain that accompHiiies it. 

(a) Frequency, — Is the patient required to urinate freciucntly ? 
Is it ciHitiiuious dnriii^ th(! (wenty-foiir hoiir.<i or only diurnal ? 
or nocturnal? If the frequency prevent her sleeping is it due 
to eystitis ? 

If the frequency ceases in the n'euniheiil pciHitiun, and only 
exists in the standing position or while walUiiif^, wc may cnnchide 
the vesical syniptoiri.s have as origin a le.sion of the neighhoring 
|>arls. It is generally a question of a uterine alTection. a uterus 
too heft\'y for its means of suspension, perhaps due to a .sclerous 
hy|>crtruphy of inflainnmtory origin, or to its means of su]>- 
port having disappeared, as Ihal happens in |H'rineaI tears with 
prolapse. 

(6) Pain. — When docs the patient sulfer.* 

Before, during or after inielurilioit ? 

Pain during micturition indicates a urethral inflanuniitlon. 

Pain after indicates an inflammation of the bladtU'r. 

471 



472 OIEMICAI. EXAMINATION OF THE URINAHV APPARATirS 



2. We can llivis rajiidly gvl an idea of the general state of Uie 
jMitient and of Iier various functions. 

S. Examination of the Urine.- — After questioning the patient, 
wc should |>rnc<-ed lo an exauiinntion of the urine. 

To do this with a man, we use several glasses; the first con- 
tJiins the swretitms of the eaiial and indicates the slate of the 
anterior uretlira. while Uie second denotes the stole of tlie |>os- 
terior urethra and bladder. 

This so|mniliun is less important in case of women Iwcausc 
the ui-ethra is short and the secretions less abundant. However, 
it has its inijiortancc; tlius if the patient micturates in two or 
three glasses, the first indicates the state of the urethra; the two 
others the state of thc_ bladfler. .\b»ive alt the third, wluch is 
obtained by the expression of tlie contracted bladder against the 
neck of the bladder. 

I will ru>t insist here on the character of pyuria or hematuria, 
or on the conditions in which these phenomena occur and (heir 
syni]>toniHtie value; that would lead us into lengthy discussion.^ 
which have nothing s|>ecial to do with the female urinark* system, 

S. Examination of the Urethra.— To do tliis examination wc 
commence by ]>Iaeing our patient in such a position so as to use a 
S{)ecidum. 

(rt) First. ini4pcct iJic meatus by separating carefully llie labia 
niajora and minora, and thus enabling us to see any lesion.s of 
the nnieotis tncinltranc and swelling or reilness. Wc sometimes 
find a reddish little tumor which is inserted immediately behind 
the meatus; it is a urclhnd polyp which explains .symptoms of 
hematuria. 

It is rare to find that the urethral mucous nirinbrane forms 
a hernia around the circumference of the meatus; generally it is 
a question of prolapse of the muc<His membrane. 

At other lime.'i we find a hard circular thickening of the mea- 
tus which indicates a maliguiint neoplasm of the urethra. 

Finally, we mav sometimes discover Uiat the urethral orifice is 
extremely dilated without any other sign of intliimmalion: we 
may then conclude that the woman utilizes her uivlhni for other 
uxcs than the evacuation of urine, and these eases are not so rare 
as one would at first suppose. 

American gynecologists insist on tlic necessity of always finJ- 




EXAMINATION Ol- THK trilETlIRA 



473 



ing out a|>art from urethritis, the state oF the canals called 
Skene's ghindK. which may he rjisily seen h_v s(-|M(ratiiig the mea- 
tus with two hair-]»ins hent al right augles. Kelly advises this 
(Fig. 365). 

(6) Then ex&fnme\he canal of the urethra. Hereogain nmpU 
inspertion {jives, in some cases, important help in our diagnosifi, 
as, for example, in certain cases there exists a certiiiii degree of 




Pio. 365.— Sk»no's glnnda (KeUr). 

prolapse of the urethro-vaHiniil wall or urethroc«'Ic. It is easy to 
recognize by exaiuiiiiiig the anterior wall of the vagina, what 
corresponds to the urethra and what to (he hludder. 'Ilie 
urethral portion, bulging like llic "hack of an nwt." has regular 
folds and is separated fi'om the more .spread out vesical portion 
bv a constant transverse furrow. 

■ 

In a general way. simple insjK'ctinn In alwnyx insufficient to 
diagnose the diseases of the urethra: wc must have recourse to 
other means, and attove all to jHilputum. Tlio index^fuiger 
being introduced into the vaginn. the palmar face is applied to 
the inferior wall of the urethra, and may cause a drop of pus to 
appear at the oHliec of tiic meatus. We thus examine the ure- 
thral secretions and find out, al the Kame tiuie, the changes in 



474 CHEMICAL KX.\MINAT10N OF THK URINAHV Al'l'AKATCS 



the cntijil, wliic-h may '»e thickened, tense, and painful as in 
the iiinannnutury condition, or, on Ihe contrary, hard with the 
sensation of a rigid cord, and nodular as in neoplasms. Finally, 
in certain cases we dtul either resistance or fluctuation, denoting 
a suh-urethral alwcess. 

This external [wilpation of the canal having Iwn done, we 
do an exploratory catheterization with a speculum and mandrin 




Fia. 306. — Esnnunntioa of vuginnl sccKliuns. 

which is gently introducet] into the Madder. We can tlius find 
out the degree of sensihihiy of the canal and its dimensions, 
(rf) The examination with the ureHiroacope will be often veiy 
useful. In order to do it we take a metallic tuhe of 8 to 10 mm. 
diameter, furnished with a mandrin to prevent injuring the 
urethral nm<'ous mendiranc during introduction of Ihe instru- 
ment. It is introduced just into the bladder; then, having W'ith- 
drawn the mandrin, it is gradually ilrawn out towani the meatus, 
while a light is throwu on the scene of o|>cration from a mirror. 




FA'AMISATION OF THE BLADDER 



475 



We can thus see the neck of Uii' IdiuitliT, tlicii the whole of the 
urethra, whieh at first looks like a flattened out tulje, then has 
the aspect of a transverse split, and finally that of a vertical 
split at the level of the meatus. We may thus distinguish 
even-where on the urethral mucous membrane vegetations, 
ulceration.s. and the oriRces of the glands of the urethra. 




Fio. 367, — Urethrowwpe. 

4. Examination of the Bladder. — (a) This is first done by 
abdominal palpation; in certain cases of vesical retention the 
bladder takes the form of a tumor projecting into the abdomen, 
a variety of tumor which we must always think of when we are 
examining a rounded and fluctuating mass situalwl aln)vc the 
pubis. Before doing an examination it is better to catheterize 
the bladder. Abdominal palpation enables us to study the state 
of the sensibility of the bhwhier. and to find out the seal of [win 
on pressure. In pressing on the bladder gently and slowly we 
may .sometimes reawaken pain; by brusquely raising the hand 
from the abdominal wall we may also provoke pain if there is an 
in flam ma tor}' lesion. 

(6) The vaginal cxaminatum permits us to find out. in certain 
cases, (Jie existence of thickening induration tumors, ami also pain 
in the interior wall of the bladder if it is combined with abdominal 
palpation. 

This bimanual palpation is an excellent means of exploration 
of the bladder, and above all, if one, as a preJiminaiy, places the 
patient in the Trendelenburg position. 

(c) Then place a speculum against the fourckettr, so as to 
depress it, and we may examine the anterior vaginal wall and 
find out if there is any prolapse of the vcsico- vaginal wall (cysto- 
cele) or vesico- vaginal fistulas. 

(d) To do catheterizatioH with a .s|H'Culum and ntamlnD. we 



^HRMICAI. EXAMISATIO? 



THE URINARY APPARATUS 



can determine Ihe depth of the bladder and the sensihilily of 
its posterior wall; in the n<)rmHl state no pain should lie pro- 
duced; if tJiere is nny sensibility, it is the bladder that is inHaniod. 

(e) Afterward lake a cwlhelerand introduce il into (he bladder 
and evacuate it. Having done tliis. inject a solution of Inke* 
warm boric acid slowly and gradually and continue until the 
patient feels inclined tu micturate. 

If the bladder is healthy, we can easily introduce 150 to iOO 
cm. cul)es without producing (he least sensation. It, on the con- 
trary, the |>Btient resents the introduction of iS. 30 or 00 c.c., 
this shows that Ihe physiological capacity of Ihe bladder is 
climini.slied. 

Finally, ctfstoscopy enables us lo form a complete knowledge of 
the vesical mucous membrane. This examination, which is 
generally done in men with a frrismiitic ci/stoscopc,^ may Ik- done 
in a woman with a simple urethroscope. In order to distend the 
bladder it sufTiecs to raise the pelvic region strongly, so tlint tlic 
contents of the abdomen fall toward the diaphragm; the air enters 
into Ihe urinary reservoir as soon as Ihe urethroscoj>e is in com- 
munication %vith Ihe atmosphere. American surgeons place the 
patient in the genu-|>ccloral position, with the chest in conlact 
witli the table, slightly arching the back, taking the ])rcc4iution 
to remove anything tight which might compress the upper part 
of the abdomen (I'ig. SON). 

We may also, as we have said, place tlie patient in the Tren- 
delenburg position, on an inclined plane, with the shoulders 
resting against shoulder pieces (Fig. .SfiO). 

.Vfter ctfcamlzintj the urethra, if the meatus is not 1 e.c. «ide, 
it is <lilalcd with Kelly's conical dilator or with ITegar's bougies. 
Introduce the sjM?culum in the direction of the urethra, inclining 
it at Hrsl a little toward the sacrum and then turning round the 
symphysis; as soon as the mandrin is drawn out, tlie bladder 
balloons with air 

Once the blad<lcr is filled an<l the urethroscope in place, we 
light up the bladder with a frontal mirror and lamp, which is 
thoroughly examined. 

If it is healthy, the mucous membrane appears smooth and 

* 8m fUrtinoiiD. Burgerjr of thti Gonito-tirinari- Syitcin in Uau. PmU. O. SlalnlMU. 
IWM. 



EXAMINATION OK THE BLADDER 



477 




Fie 36S. — Dllutfttion o( Ute Itladd^r, vAKinii and rccliiro In tli« gcnu-nrotoral nointioo 

(iifiL-r Ki-lly). 




9. 369.— ExADiinKtlon of tli« bteddvr with pationt io the Tramlpt^iibant pMlM 



478 CHEMICAL EXAMINATION OF THE URINARY APPARATUS 

pale or with some vessels showing. Examination with Nitzc's 
cj'sto-scope always gives the impression of larger and redder vessels 
than with the direct urelhroseopic examination, l)eeausc with this 
latter means of exploration, the bladder liecomes less congested 




Via. 370. — Kelly'H ooiucal diltttor. 

by reason i)f ilie elevated jiosition of the pehis. With the 
Hrelliroscojjic lube, we inspect successively the trigone and 
diffei-ent segments of the bladder. 

5. Examination of the Ureters. — (rr) Abdominal patjyation 
enables us to find out any pain along the course of (he ureter. 




Pio. 371. — Relalionii of the ureters wlUi the va^iu (DnrllfiuM). 

(6) Vaginal examination gives more prei'ise indications. 
When the fing«'r is introduce*! into the vagina by following the 
median line as far as the cervix uteri, one cannot feef the ureter, 
but if the finger lieing in the anterior fornix, is tnrne<l hilerally we 
fe^'I anterior to the cer\-ix, in describing an arclu'<I course around 
the uiilerior fornix and stopping a little distance from the median 
line, a little hard cord, the ureter. Normally it ts hard to dLs- 



EXAMINATION 01" TIIIC KIDNEYS 



479. 




ver. If one finH.s a ihirk and han) rord. (luring vaginal rxatn- 
ination which is uutlincd against the vaginal vault, and situated 
outside the median line, we may be sure that we have to deal with 
a diwast'd ureter. 

G. Examination of the Kidneys. — Examination of the kid- 
neys reveals nothing in ]>arlicular in a woman ; hinuiniial palpa- 
tion is generally carried out as in man/ 

In order to ajipreciale their functional value, we may have 
recourse either to urethral catheterization, or to intravesicaJ 
separation, so simple in its technir that any doctor may practice 
it without any preliminary education with the instrument con- 
structed by M. Genlile for our old assistant. Dr. Luvs. 

This apparatus is introduced cluseii into the bladder; make 
the india-rubber septum bulge, an<l applying the instrument 
against the inferior wall of the l>ladder. we are able to make a, 
recess, Uie urine from each kidney aecunudating on each side 
of the .septum, and afterward evacuated externally by the two 
tubes. 

The urine flows naturally and every 40 or 95 seconds we may 
sec drojis issuing which correspond to the intermittent ejacula- 
tion of the ureters. 

Tills apparatus has given me excellent results. 

Catheterization aj the meter, which one is able to do with the 
prismatic cystoscope In man, is most often <lone In woman directly 
tlmmgh a urethroscopic tube. Its teehnic has lieen fully worked 
out by the American surgeons. Kelly in particular. 

In onler to avoid dilatation of tlie l>ladder ivhcu the air enters, 
it Is recommended to Introduce the urethruscopic tid>e to partly 
o|»cn the vagina in such a way that it fills with air, which presses 
back the vesico- vaginal septum toward the abdominal wall. 
In these conditions if one introduces the uri'throscope. this 
septum is raised a little toward the vagina, but rarely above the 
horizontal, and thus its ureteral orifices arc brought on a level 
with the speeidum. 

In order to see them, draw back the urelhroscopie tube until 
the mucous membrane of the deep orifice of the urethra appears 
on a line with it.s internal extremity. The handle of the instru- 
ment is then raised, and the speculum directly pushed into the 

' 8oc Ilartciiikiiii. .Surgery of the (i«nito-uriEi>ry Orgiuu in Man. 



■ISO CHEMICAL EXAMINATION OF THE VRINARY APPARATUS 

bladder to a depth of three cm. Lowering this handle in such 
a WAV as to bring the end of the iin-throsi-upe on the .same plane 
as the base of the bladiler. we progressively incline the instrument 




Pia. 372. — Luyt' wpuator in pOHlloB. 

laterally until one seen the ureteral orifice, which ordinarily 
apjK-ars when one has traversed an arc of 15" to 80" about the 
median line. 

In some cases, following an inHanimation of the vesical 
mucous meinbnine. the ureteral orifice doi-.s mU apjicar clearly. 
We are then guided by the discharge of urine at its level and we 
may insert a fine metallic stilette in order to find it. 




:fl\pter ir. 

SURGERY OF THE URETHRA. 

Summary. — 0[M!niU(in.t on the im-tlira (.cntlirtrrizution. tlilatalion, inter- 
nal iirethpolomv. external urethrotomy, urethrwrtomy. operations for incon- 
tinrntv of urine). — Trewtiiient "f diseases of tlie un'tlira (wound, foreign 
bodi&t. ralculi, infUmmation, suburethral alucnues. urethrocele, jirolajiKr of 
mucous menihrnnf. tumors). 



1. Operations on the Urethra. 

Catheterization. — (_ atlieterization is one of the simplest ofiera- 
tions, owing to tlie sliorlness ami n'<;tiliiiear direction of tlie 
female canal. The only precaution to take is only to act with 
the strictest anti.sepsis. Wc must only use sterilized instru- 
ments. Ocan the rnealus thoroughly and only do the opcrattun 
under visual control. 

The meatus i.s iiurnially found above tlie tuliercle which limits 
anterioriy the anterior column of the vagina. Above lliis land- 
mark is the con.stant p(»silion of the external orifice of the urethra. 
It is sufficient in order to do the catheterization to engage the 
end of (he sound well within it, then to .slightly louver its extremity 
and at the same time push it forward. Before the extremity 
of the sound penetrates the bladder it is well to place one's thumb 
over its extremity in order to prevent the urine from flowing 
anywhere except into the destined receptacle. 

Some ditfirulties which are exceptionally met with are con- 
nected either with the meatus being taken for ])eri-nr<'thral 
excrescences or by the t»ent Imck i)rotul>erance of the anterior 
tubercle, which lies normally below lliis orifice, or that Ihc canal 
is deviated anteriorly due to pregnancy or a uterine tumor, or 
backward due to a dilatation of its interior wall from a urethrocele. 
If we bear these in mind we will easily avoid them. 

Dilatation of the Urethra. — The meatus is the least dilatable 
portion of Uie urethra ; uUo when it is smalt and rigiil. it is well 

» 481 




482 



SUROBRY OV TUK UREIURA 



hpforo commencing to Ho the dilatation to make some small 
lateral iiicisioiis. 

If we wish to obtain a moderate dilatation, for exitmple, in a 
case where we wish to do a cystoscopy, or a st-jwiration of urine, it 
is llien sufficient to pass some Ilegar's liougies or Benifjues' 
straight diluturs into tlie urethra. 




Flo. 373. — Bci^r't boii|^(u< witli double- jcmiliintion. 
If one [jroposes to do a free dilatation, we may use Hegiir's 



bougi 



d 



duully 



IS the caliber. 



lucreasii ^, 
In order to dilate the urcthni and vesical neck, we may use 
special instruments such as Tripier's hollow dilator, Guyon- 
Ouplay's' dilators with accomjwnying mntidrins. or Kelly's 




Fio. 374.— Tripier** bullow iliUlor 



cotiicid dilator, etc. The important point ts to act with caiilion. 
never to dilate brusf|uely. and not to go beyond a caliber of 20 
ram. diameter. We will thus avoid the somewhat rare complica- 
tions such as rupture, tearing of tlie canal, hemorrhage, infiltra- 
tion and incontinence of urine. 



t'lo. 3;&,— PuUAu'iBlralsht anthrotoow. 

These wide dilatations have been advised in the treatment o 
certain cases of painful cystitis. They arc aUtve all useful tu 
preliminarv npcratioii lo a digital cx]>tori(lion, to the exiraclion o 
a foreign body, or u curettage of the bladder. 

• BvtOMnii, Painfitl C>'iitttlii and lU Tmtranil. Tk. d» Parit. Q. SUtnheil, 1887. 





OPERATIONS ON THE UTEEU8 



463 



Internal Urethrotomy. — Intrnml urollirotoniy has only rare 
imlirations in wouieii. It is carried out on ihe superior wall 
wiUi Maisonneuve's urethrotome, or Iwtter with a straight 
urethrotome. The opcraliim and followlug ti-eatment have the 
same consideration ns in the case of man.' 

External Urethrotomy. — -This is very simply done in woman 
bv direcUy incising Ihc ui-elhro-vaginal septum. It may also i»e 
done as Legiien advUc.s hy the Jtitb-ti/niyhyirettl route, which enables 
us to surely avoid a fistula. 

After having exposed Ihe vidvar vestibule by separating the 
labia minora, we make aliove tlie meatus and between this and 
the ditoris a curved incision with its concavitv inferior. With 
the bistoury scissors or finger we separate Uie uretlira from the 
symphysis, slopping laterally when we reach the corpora caver- 
nosa, which we nuist save, cutting through and tying, if necessary, 
tlic vessels which go to tlie uretlira. This is incised on a line 
nith its superior face on a cannulated sound. 

Once the operation is finishtKl, wo suture tlie urethra after 
placing a sound in position and closing up the sub-symphy.seal 
wound by buried catguLs, whicli lift up the meatus toward the 
clitoris and give to the canal its normal curve. Some superficial 
.silkworm-guts unite (he tK>rdcrs of llie vestibular incision. 

Urethrectomy.— l-iCgucu and Duval recommend the sub- 
sympliyscal runle and preliminary incision of tlie urethra on its 
superior wall so as to gauge from the eonmiencement the extent 
of the parts to be removed. Having done this, free the interior 
wall of the canal to the extent »>f Ihe future seeljoii. Before 
doing this, we insert two paraurethral sutures, one on each si<le, 
in the canal in orvler to prevent its retraction toward the bladder. 
The urethra is cut across in front of these sutures and fixed in the 
[Hwtcriorangleof the vaginal wall. This is reconslitule<l by suture 
in front of the new meatus. 

When it is necessary to extirpate all the urethra, llie view 
obtained by the suli-syniphy.s<ral incision is not suflicient: Zweifcl 
combines it with symphysiotomy. Mac Gill commences by a 
suprapubic incisitm, tlien lifts out tlie tumor by the vagina, 

' See HartmanB, Surg«ry ot ihe Ceiuto-uriruir}- Orgwia In Man. Pana. Q. SUlobtU, 




4»4 



SURGERY OF THE tiRETHlU 



which ail assistant presses back below with two fingers intro- 
duced into the bhuhlcr. 

The functional result of the partial extirpations is excellent: 
on the contrary, total rt-nioval, with incision of the vesical 
sphincter, is followed by incontinence. -Uso certain surgeons 
coiriplelcly dose up the u ret hro- vesical wound and establish 
a hyiJogastric meatus, on which a urinal may easily be applied 
(Mac Gill. Zweifei. lialtle). 




Fio. 376. — Tmce of the uiaitrion for urrthncitomy. 



These urt^thn-ctimiics have been done for neoplasms;' it is 
necessary jjenerally to do at the same time an extirpation of 
inguinal ganglions. 

Operations for Incontinence of Urine.— A great number of 
0])erations liave l>een advised for incontinence of urine of urethral 
origin.'' 

' We hiivc liud oi'cusion to do willi llie soooeBS of a liumblc rescption of the termiiml 
portion of the urrthra for ono ciuc. up to now iiiilte iiniijiut, of tuhcreulou* Klruoturr, 
noftlUiii; by tin iu!]ivkI ihoifV of eonM Fictions of tiie laau.- iMiatv iu the rectum, <IIftrt- 
miinn, ilvpprtrupliii; TiiliP'toutoHiB witli Itcaiilting Sten«tiiii of thu L'rctbrn ia a Wonuui. 
Th. d« P'JrM, '1, Stcirhfil, MI07, p. 1.) 

' CotiniiJ iH.), Upentlive Treatmoat of luuontiueuoe of Urine In Womeu. T\. 49 
Pari*, G. Stciabul, 11)06-1907, N'u. 63. 




OTERATIOXS OX THE t'TERUS 



485 



Some wish to constrict the cnnal: we may do this very simply 
by doing an anterior calporraphy, siib-urcthro-vesical,' reconsti- 
tuting at i\\f inferior part nf llic urethra a solid cohiniii and at 
the same time tightening up the periuretliral tissues. Associates! 
with a |)orincorra])hy, tlie anterior variety suffices most often to 
cure incomplete incontinence of women witli prolapse and 
exaggcrate<l laxity of the pelvic tissues. 

Gersuny lias cndeavort-il to obtain the same result by doing 
around tlie cervix a scries of injcctums of paraffin.'* With a 





Fio, 377. — Operation tor in- 
eon^ODM of iirin»r. Trace of 
tfa* iDolaioii. 



Fiu. 378.— The iirrthnt hM 
lieen diaoected. A (old !• 
aindr on il« superior whU. 



sj'ringe, Uic body of which is heated by a circulation of hot 
water, he injects, after local anesthesia, about 2 c.c. of fusible 
paraffin at .1.5° in the neighborhood of the cervix, circumscribing 
this with a series of small nuusscs oi paraffin. 

Pawlick made an operation displacing and obloiigating the 
urethra; Durot and we also construct llic urethra and lift up the 
meatu.s toward the clitoris. Gersuny twisted the urethra, after 
dissecting up. l'ous.son combined torsion with rai.sing of the 
meatus. Fritsch does a suli-pubic incision, separates the urethra 
and blarlder from the .symphysis, excises a long longitudinal 

' Thi* nul'-iirtthnil co!|)(irrnphy inny be done bj; drnuilAtiini or bjr >plillinx. 
• Cionunv. I'ftfaflinpinspritiiiiiit bci liionnlmcnli& Uritiu>. Ctmtr. Bi./iir Ojn., IWO, 
Stein, riir.-inj Th. de ParU, Stul^urt, 19CH. 



i 



SITROERY OF THK URETHRA 



band From the su[)cnur wall of the c-atiul and cervix, and tlien 
unites tlic urethral wound with a continuous suture. 

The procedure which appcurs best to us is that dcscrilwd hy 
Albarran; it is a rational combination of several oi>erations thai 
are done anteriorly. 

A longitudinal incision commences at the clitoris and encircles 
the meatus. A triangidar incision is made below this as in 
Fig. 317. The two triaiijtular flaps having been dissected up, 
the urethra appears to form the base of the wound. This is 



4 

J 




Fra. 370. — The folded urctJira boa boon tunied in tbruush > half circle uai tbca lifutd 

uji below tlie olitoria. 



disserted up gradually, preserving its nuiseular Uitiic and sepa- 
rating below the vaginal wall up to within a little of the neck of the 
bladder. It is then easy to draw down the canal and to make on 
its su[)erior wall a longitudinal fold which constricts it (I'ig. 378). 

The urethra having been constricted by a longitudinal 
superior fold is turned in for one-lialf a circumference and drawn 
upward; the meatus Is fixed immediately lielow the clitoris and 
then the vaginal wound is sutured (Fig. 370). 

In case of rei>ellious incontinence, Hofmeier' after an anterior 
coJpotoniy, lowers the utenis into the thickness of the urethro- 
vesico- vaginal septum so that wo thus make a sort of sub-ureUiral 
' llufmoler. Am,, dt gyntt., Puia. IBM, p. 701. 



^ 




TREATMENT OF DISEASES OF THE ITRETHRA 

plug which compresses the canal. We have had recourse lo the 
same procedure and we have found it very useful.' 



2. Treatment of Diseases of the Urethra. 

Wounds of the Urethra. — -The recent wounds are treated by 
immediate suture and the ancient by denudation and suture. 

Foreign Bodies and Calculi.— If the fon-ign body or the 
calculus is near the meatus, visible and easily accessible, it is 
sufficient to dilale the meatus of tlie urethra in order to make 
the calculus come out by pressure from behind forward. If it 
is further back, it is extracted with a curette or belter with a 
pair of forceps introduced through the urethroscope, and with- 
drawing at the same time the calculus, forceps and uretliro-seopic 
tube. If it is impossible to withdraw the calculus, we must do 
an external urethrotomy. In a certain number of cases Uie 
calculus is lodged in a diverticulum of the urethra; it is neces- 
sary, by a vaginal incision, to remove the calculus and to excise 
the pocket, terminating with a suture in two planes. 

Urethritis. — At the commencement if there is an acute inflam- 
mation not only of the urethral, but also of all the vulvar region, 
we must give hot baths, vaginal injections of permanganate, 
applications of compresses soaked in the same solution, and 
prescribe abundant drinks. In some few days we give balsamic 
products, and if necessary, we have recourse to lavage of the 
urethra. These may be done witli or without sound. If we 
use a sound, as the urethra is short, we should use straiglit 
sounds, with a back flow, which are introducci! as far as the 
cervix; the liquid comes back to the meatus, washing the canal 
from behiiKl forward (Fig. 380). 



=<=*■ 



Fio, 380.— CnnnnU with rooiirmnt flow. 

Often reinoculation occurs through the existence of a series 
of olher iiifeclioiis loculi in the vagina, the uterine cervix, 
Bartholin's glands and above all in the little pockets described 
by Skene below the meatus. 

' For the tcuhnic of thU oporntion nee Colpoceliot<imy. 



488 



SUKUERY Of THli L'RETHRA 



We must wash out these glands in a special manner, injecting 
into Uiem, through fine cnimulas. some (lro{>s of a solution of 
potassium permanganate, I to yOO, emptying this hy pressure 
and then re-eomniencing the injection. Carbolic acid in con- 
centrated solution and nitrate of silver have been recommended. 
In order to put an end to the suppuration of lliesi,' diverti<-ula it 
has been adviswl to split the wall of mucous membrane which 



crTf' ^i 




Fio. 381. — Stcriliinl)!!! Byringe. 

separates them from the canal or to destroy them by insinuating 
into them the fine point of a galvan(j-cautery. 

At a later period we have advised lavage of the urethra with 
a solution of oxycyanidc of mercur)* and applications to the canal 
with pure ichlhyol. 

It is important to continue the treatment during the <Iuration 
of menstruation and to pursue the infection wherever it 18 
localizMl and not confining oneself to the urethra, as aulo- 
infection is very frequent. 



Fio. SSa. Tic. 3s;t 

FIdo («Dau1a« (or Injections o( llio [lora-uretliTitt c&nal*. 

A variety of urethritis. observctJ above all in women and 
rebellious to ordinary treatment, is proliferating iiretlirttl^, which 
may cause small urethrorrhagia and sonu-tiines [uirtial retention 
of urine. If the lesions are limited to the terminal part of the 
canal, wc may oiilain cure hy doing a partial resection of the 
uredira: if they extend as far as the neck of the bladder, the 
resection of the urethra is not to be considere<l as it would lead 
to incontinence; Ix^ueu advocates, in such a case, to destroy the 
vegetations after having practised a sul>symphyseal external 
urethrotomy. Wc have found simple destruction witli tile 
galvano-cauter)' tpiile useful, to be done in several sittings, 
advancing little by little into the depths, after liK.-aI anesthesia 
and through the urelhroscopic tube. 



TREATMENT OF DISEASES OF THE URETnRA 



489 



Sclerous urethritis U exceptional; it is ti'eated nith mu&sage 
ami dilatation <ionp witli Beniques bougies and pushed as far 
as Nos. 55 aTid CO. If it fails, we may have recourse to internal 
urethrotomy or even to external urethrotomv l>y tlie suh-syniphy- 
seal route, removing the callosities and leaving; without union the 
superior wall of mucous membrane so as to thus a<ld a piece 
to the urethra (T-eK"*"")- 

Suburethral Abscess.— Suburethral abscesses,' which often 
open into tlie urethra, may be follower! by uretliro- vestibular or 
uretliro-vaginal fistulas; they are treated by a broad vaginal 
incision, curettage and tanipoiu'ng. If the intervrnlion is 
followed by a fistula, it is closed secondarily willi a little operation. 

Urethrocele. — Sometimes confounded with cyslocele, urethro- 
cele is easily distinguished by the fact that the seat of tumefaction 
is at the level of the urethra, in front of a transverse furrow, 
always visible on the vaginiU wall an<l corresponding dee]>ly to 
the neek of the bladder. The introduction of curved sounds into 
the canal shows that it is a pueket corresponding with the 
urethra. 

To operate split the whole thickness of the pocket on a 
cannulated sound and excise a melon-shaped area from its 
inferior wall an<l afterward suture the parts together. 

Prolapse of the Urethral Mucous Membrane. — Treatment con- 
sists in excision followed by suture, splitting the prolapse in the 
middle line antero-posteriurly we insert at each exlreinily two 
catguts which unite the mucous membrane of the urethra to that 
of the external face of the meatus ; then excise successi%'ely each of 
the halves, right and left, suturing the mucous membrane as the 
section arlvances, doing in all points an operation similar in that 
of Wiitehead for hemorrhoidal prolap.sc of the anus. 

In iiifjints Sloeckel after drawing down the prolapse ties it 
with a hue silk on a Nelaton .sound; a cure is ra]>idly obtained 
after necro.si5 and detachment of the straiigltHl mucous cylinder. 

Tumors. — Small excrescences (mucous polyps, papillary angio- 
inata, caruncles) which are observed often enough at the level 
of the meatus and are excised with curved scissors; then their 
surface of implantation is cauterized with nitrate of silver: if it 
is large enough insert a catgut suture. Fibromata and myomahi 
■J. Oftury. rpriuroUral .MyumkUt la Wotuui. Th, i4 Pari*. Ism-ISM, Ko. IU3. 




490 SURGERY OF THE URETHRA 

are extirpated by enucleation. In presence of cancer of the 
urethra^ we should do urethrectomy. A particular point merits 
mention, i.e., the possible existence of periurethral malignant 
tujnors. In such a case spare the urethra without great incon- 
venience from the point of view of recurrence. In all cases we 
should remove as well as the tumor the inguinal glands. 

■ Percv, Priiii&rv Ckmnomft of the Urethra in the Fem&le. Am. J. of Obilel., New 
York, Apiil, 1903, 1. 1, p. 457. Ymuio Karski, Ueber prim. Ksra. der Weib. HsrarOhre. 
ZeiUck./. Gtb. u. Gyn., 1907, Stuttgart, T. LXI, p. isl. 



CIIAriEK III. 

SURGERY OF THE BLADDER. 

Summary, — 0|>f niUnn* on Un' liliuicl<-r (vo-ttilmlnr spclion. colpoevSfot 
omy. colpocvstostoiiiy, lithotritv. curuttagc). Trcatinciit of discasv-i uf the 
bliidder (foreign IkkIk-s nml calfiili, fynlitH mi<l pn>Iii])i>r of the vesical 
mucous mcinhrane). 



I. Operations on the Bladder. 

CyBtotomy.^The bladder may l>e opened in women in various 
ways: ulmve the piihis, .siii>riii«ilii(' cystotomy; lielow tlie pubis it 
is the old vestibular section of Lisfranc; by the vagina it is 
colpooystolomy. 

Perineal SecUoo. 

Vestibular section, suggested and practised in 1823, has been 
taken up again latterly by Legueu under the name of snb- 
symphyseal section. The first stages of the operation are 
identical with those of subsymphyseal external urethrotomy. 

The superior face of the iin-tlira being freed, the finger 
separates the retro-pubic fibrous tissues, aided by a scalpel, the 
point of whi(-h is d{reete<l upward so hs not to injure the canal. 
As soon as one has reached the level of the Iihuhlcr, the separation 
in very ea.sy. 

We may then incise the bladder or cervix. In principle il is 
better to respect the latter. We make a vertical incision in il.s 
wall lM*tween the two ascending veins of Uie anterior face of the 
bladder and then place on each lip a suspensory suture so as to 
be able to explore the interior of tlie urinarj- reservoir. 

When the o]>eration is finished, eIo.se the vesical wound in one 
or two planes; suture the .toft parts of the vestibule with the aid 
of interrupted catgut sutures, leaving a littJe median drain which 
is soon rcmovetl. \ catheter is left in. 

401 




492 



SDRGKRYOF 




Pio. 3SI.— Cftthet«r (or vaginal 
M>ction (llnrtniAnn). 



Fio. 386.— OoliMcyHtotomy. The Oktbetcr makw 
the YMioo<ragiiiM wptuin btuco. Tbe iadnon com* 
Ri«ne«a knt«iiarly « littlo b«hjna th« tmniTvnw croon 
whi«lt Indioates tli« Ritufttlou of tlie n«ck of th* 
biBddcr. 




^^^^^■^ OPERATIONS OS THK BI-VDDER 4fl8 

This procedure is particularly applicable to cases where the 
vaginal route cannot he used iK-cause of the hymen. 

Colpo -cystotomy. 

The patient is plat-cd in the usual position for vaf;iii(j-perineal 
operations; the bladder is washed out, then moderately distended 
by the injection of 1,50 to !200 c.c. of lukewarm boraeic acid. 

An assistant draws down the posterior wall of the vajjina with 
speriduni; wtlh an ordinary catheter or Ijctter with a special coude 
catheter, whicli is j^rooved for a distance of about 4 cui. (1 1/2 
inches) ah>ng its intravesical convex portion (Fig. 384). This 
catheter shouhl he maintained in the median plane so as to save 
the ureters. The surgeon, with his index-finger against the 
groove, punctures the vagina abunt I cm. l>ehind the neck of the 
bladder: by aid of the grooving, he is enabled to push in the 
bistoury from I 1/2 to 2 cm. and to incise the whole thickness 
of the vesieo- vaginal septum by a sort of transfixion; he is thus 
certain of avoiding any slipping and of being able to make a 
section of the vesical nmcous membrane corresponding vcr)* 
exactly to that of the vaginal nuicous membrane. 

The intra- vesical operations (extraction of a calculus, of a 
foreign body, etc.) having been done, we suture in two planes the 
incision in the septum and tlu-n place in a callietcr, which is 
left in for 10 to U days. 

Rochvt, fvaring ttie cnnnociitiv*.' furniiitioii of « ti.itiila, inukes aliout 1 cm. 
behind the meatus a transverse inmion of S to S cm. about, wliich only 
giw% through tlit^ vn^inul muroits membrane. 'Hicti lir so|)nrates witli the 
grooved sound or ivilli blunt seissorx thv viiginsi niucuus membrane of the 
uretlirn ami bUddt-r; h<- then ineUcH llie latter. 

Kelly places the patient >n the geiiu>pcctont1 position, punctures the 
bladder witb a <^(ind<^ li«^nt nt rjj^bt anf^lc^. aliout 1 1/3 cni. from the rt'rvix 
uteri and tben brings tlic bistoury into the mi'diun line Jn Die din'cliuii of the 
uretbrit unlil lie judges the incision siiflicicntly large. 

' Colpocystostomy. — If we propose to keep the incision in the 
vesico- vagina] septum permanent, in ortler to make a fistula in 
the bladder as is done in certain rebellious ca.ses of chronic 
c^titis, it is well to prolong Ihc incision a fair distance backward 



494 



SfRGKRY OF THE BLADDER 



until we reach the npiglihorliond of tlip cervix uteri in orrler to 
avoid persistence of a cul-de-sac at this level and tlien as the 
wound has a tendency to lical spontan(K)usly and closes rapidly, 
stitch the vesical mucous membrane to that of the vagina. 

It is unfortunately not always possible because of the friabil- 
ity of the mucous nienibraiie and its adherence to tlic adjacent 
layers resulting from iuftamniaton' conditions. In such a case 
we must l)c content with passing a largi- drain into the bladder, 
from the urcthrn to the fistula, uniting its two extremities with 
a suture. After a few days take the drain out and the Astula is 
thus formed. If later it has a tendencj' to contract, enlarge it 
with the Ihermo-cautcr}'. 

It is well to use boracic acid to wash out the vagina in order 
to prevent stagnation of urine ami the fonnalion of phosphatic 
cfiiieretions. Although there may be from time to lime (il)rinous 
detritus obliterating the fistula, we should always make our vesical 
injections with gentleness. Tliey [hiss by the urethra and come 
out by the fistula. 

Lithotrity. - Lithotrity in a woman is more difficult than in a 
man which is due to the absence of a grown recess and to the fact 
that fnigmenl.s of i-alculi, instead of becoming united are dissem- 
inated over the whole extent of the bladder. We should also 
follow Guyon'scoun.sel' and create an operative Held by pressing 
down. witJi the help of the litholiite. the vesico-vaginal wall near 
(he neck. This is done in order to cause the calculus to curve 
there. It is then seized and broken up. 

Curettage of the Bladder.— Curettage of the bladder has been 
done through the unihra.^ After anesthesia ami wa.shing out of 
the bladder introduce a lonp and sharp curette and then using 
tlie vaginal finger a.s a support we curette the interior wall of the 
bladder. For the remaining surfaces of the bladder curettage is 
always le.ss perfect as (he wall recedes under the pressure of the 
curette and risks being {}erforated. It is important to curette 
thoroughly the region of the neck of the bladder and once the 
curettage is fini.shed. do a free lavage of the bladder (I to lilOO 
subhmate) or nitrate of silver {I to 500). creosote (1 in 100), and 
even pure tincture of iodine. Pezzer's large catheter is left in 



* Guynn. Anna}" of ffynieoloi 

* Oouraier, Trckliucnt o( ~ 
1694. 



, PkHs. l»ftl.T. I. p. 241. 
lUiou* CysUtis in Woman. 



Th. dt Pari*, a. StainlwU, 




TREATMEXT OF DISEASES OF THE BLADDER 



405 



and sen'es to instil each day, in the morning nitrate of silver 
1 to 50 and in the evening gomcnol t in iO. 

i. Treatment of Diseases of the Bladder. 

Foreign Bodies and Calculi. — Foreign bodies are often fre- 
quent!}' oiiservc'd in thr fenialo Miidder. In a great number of 
coses it is possible to extract them per vins iiaturalcs. This 
extraction is facilitated by using special instruments, such as a 
blunt litmk which locks. 

It is made by Collin and reronmiended for the purpase of 
drawing hair-pins out of tlie bladder, these being the most 
common of foreign bodies. It is generally easy enough to 
seize the pin, but often difficult lo extract it. Tlic pin is inlr<^ 
duced by its rounded end; once in the bladder, it props itself up 



4»«s»s 



^ 



Via. 3S6. — Looking book. 



by its two poiuLs against the neck of the hlnddfr or takes a trans- 
verse [josition: once having seized it. we must draw it gentiv 




Fiu. 387. — Needle *ciicd uith Uic blunt ond, eurvrd luiok itt jtulltHl ihrou^ lfa» urothro- 

Huopic tulie. 

out. First determine the situation and ilii-ection of Ihc foreign 
body with the urethroscopic tube, and then under the ^'isuol 
control bring it to be in good position and extract it. 

If this fails, dilate the neck of the bladtler and with the finger 
turn it round and draw it out with its convexity toward the cervix 
and tlius remove it with Uie greatest facility. 




406 



SITROERY OF THE BLADDER 



If the foreign hody is I'licrtistcd l>rcak up witli ii litbotntf the 
pUosphatic incrustations which surround it. 

If the foreign Iwdy cannot I>c extracted by the urethra, then 
do one of the vesical sections, particularly colpo-cystotoniy, whicli 
although not lo be strongly recommended for removal of neo- 
plaxriLs, is exeelK'tit fur the removal of calculi and foivign bodies. 

Cystitis. ^The general indications of treatment are the same in 
botJi sexes. In a woman with cystitis wc .should always look for 
any concomitant affeetion of the genital system which may cause 
and keo]) up the innammation uf the bladder. This queJiUon of 
relationship between the disease of the genital and urinary 
systems in women is still ba<ily known an<l demands more study 
to elucidate it. 

Propli If lactic treatment is verj- important; we still see too many 
cystites following on calhelerization. Wc should avoid useles.1 
catheterization and only do it when the bladder is felt distended 
above (he pubis. The important point is to have the strictest 
antisepsis. 

C^itlielerization which is usually done by a nurse demands as 
many and as important precautions as a big operation if we 
wish to avoid formation of a cy.stitls. This may even develop 
in the absence of catheterization after the extensive operations 
for cancer as example. In the.se cases, as in those where one is 
obliged to have recourse to catheterization, we should first give 
a little urotropine. 

Gangrenous cystitis, which has often been studieil rluring the 
course of retroflexion of the gravid uterus' and after colpo- 
hysten^etomies Utr cancer, may be prevented by an appropriate 
treatment consisting of redressing the grand uterus at the fourth 
month and (he peri ton i /.a ti on of the dentided parts of the bhulder 
after removal of the cancer (Kronig). 

For certain forms of rebsliwtui ci/xtitis eolpocystostomy. gener- 
ally d<me in America, renders useful service by as.4uring the drain- 
age and continuous elevation of the bladder. The fistula ought 
only Ih! closet) when lite Itladder condition is cunul, if the pus 
has disappeaied from the urine and the pressure of the oval- 
headed sound on the internal wall of the Ma<lder causes no pain.* 

■ Piiwitl uid Varnkr, Ann. Je uyn., Vuia. 1SS7. T. VI, p. SS. 

* llsrunnnii, Painful CsTklitisMidil-TmlniiMit. Th. dt FoH$, G. Stmnlicil, IttM 



TREATMENT OF DISEASES OF THE BLADDER 497 

Prolapse of the Vesical Mucous Membrane. — This condition 
has already been observed to occur through the meatus.' It is 
distinguished from prolapse of the urethra] mucous membrane 
by the absence of an orifice in its center and by its complete 
independence of the canal in all its length. Treatment consists 
in excision of the prolapsed mass after hypogastric cystotomy so 
as to see well what one is removing and not cause a lesion of 
the urethra. 

■ Vary, Hernia of the Bladder Through the Urethra. Th. de Bordtaux, 1894-95. 
No. 82. ViUftT, Arch, proirine. de Chir., Paris, 1005, p. 373. 



33 



CHAFIEK l\. 



TREATMENT OF URINARY FISTULAS. 

Summary. — ^V'ei^ico-vugiiml fishiltiK. — PntphyUctic Ircntnu-nt.^ — i?{>oon 
tanoous ruren. — I'reparalorv troatmpnl (cjstitis. strictures of the vagina),^ 
0(icrutitiii.^<ierKTal terhnic. — .Simple (Icniidutlon. — Trtraliiiciil of fi.stiilax 
situated opposite tbc cenix uteri, — Operations in several stages. — Special 
procfiliiroi HpplicHbie to liirfte Ioikps of tissin'.^Utrro-voMcal fivtula^ (direct 
and indirect obliteration). — Utero-vaginal fistulas and destruction of the 
uri'tiira. — Fisliilii.'" of tin- iiR-tlira (T. [iniplivluctic anil ciirulivc, T. bv direcrt 
obliteration, by urethral grafts, bv nephrectomy). 



Tliey are 



I . Vesico-vaginal Fistulas. 

Vesico-vagiiial fijitiila.s arc (Iiic t<i various cauiws. 
frequently observed after tlifficiiit labors. 

Following on j)roI(mj;c(l compn'ssioii of the fetal head, the 
tissues become gangrenous, and as a result there is often con- 
siderable loss of .substancv, cniii[>liratt'(l l)y the pn-senee of 
faulty cicatrices and adhesions to the neighboring liones and 
partieuhirly the pubic arch, l-'roin this develop multiple 
lesions the cure of uliieh is sometimes uicwl difficult as these 
lesions may occur not only in the vesico-vaginal .septum, but also 
in Uic cervix uteri, in other part.s of tlie va^'ina and in the urethra. 
To-day owing to the improvement in obstetrics the number of 
tliese fistulas has considerably diiniiii.slu'<l; on the contrary, ojie- 
rative fistulas have increased in number. They are met with 
after vajrinal hysterectomy, total hysterectomy, and in particular 
colpohysterectoniy for cancer and even after certain surgical 
hitcrventions such as symphysiotorav and vaginal Cesarean 
section. 

The treatment of vesico-vaginal fistulas is .still a question of 
the hour. Numerous prcK-edures are published every day and 
many of them are re-editions of old methods. It is important to 
recognize the variability of the lesions we have lo deal with, thus 
obliging the surgeon to recognize divers procedures he has to 
follow according to circumstances. 

498 



n 




VESIOO. VAGINAL FISTULAS 



1S9 



I. Prophylactic Treatment. 

ProphvlacUc treatment consists in tlie union of vesical 
wounds at tlie time of their production. A non-sutured wound 
may sometimes heal spontaneously by simply leavin;^ a catheter 
in, but we must not count on this fact, hut always try and get 
immediate union of the operative lesions of the bladder. To 
obtain this union, we avoid the insertion of perforating sutures 
and particularly those of a non-absorbabic character like silk. 
Under such circumstances we are exposed to the migration of the 
suture into the bladder and the formation around it of a secondary 
calculus. Do, therefore, a suture in layers and afterward leave 
in a catlicter whenever possiltlc and parti<'ularly after vesica! 
lesions following on colpohysterectomy. instead of leaving the 
line of union in contact witli the vaginal wound and of inserting 
a drain or tampon, try and cover over the line of suture with 
the drawn down vpsico-uterine peritoneum, which is the best 
means of obtaining healing by first intention. 

This projiliylactic treatment is evidently not applicable to 
fistulas following on labor. whi<'h result from the separation of 
gangrenous tissue and cannot consequently he immediately 
sutured. It has been advocHted liy some lo obtain a covering 
by cauterization and in particular by touching up with nitrate 
of silver or the thermocautery. 'I'he efficaciousness of this 
method has not been establislu'd. Perhaps, if it is crowned with 
success, it may be merely a question of one of those spontaneous 
cures seen in a certain number of cases. It is the opinion of some 
gynecologists that these cauterizations are injurious, because, if 
a cure is not obtained, tlieyonly lead to the formation of cicatri- 
cial tissue, the presence of which renders later intervention more 
doubtful and difficult (Stoetrkel). 

It has been advocated by others that to favor the spontaneous 
cure of vcsieo- vaginal fistulas we sliovdd put the patient in certain 
positions, in ventnU decubitus to unilateral decubitus on the 
opposite side from the fistula. All these methods have been 
abandoned now-u-days. 

We confine ourselves to the removal of foreign bodies if there 
are any, to vaginal irrigations and to pelvic baths and to leaving 
the catheter in. 



500 



TBEATMEST OF URINARV FISTULAS 



As these spontaneuus cures lake a certain time to come aliouf 
wc do not i 10 mediately operate on vesico- vagina J fistulas, inas- 
much that after labor the tissues are more friable ami more 
vascular, that in the fistulas which supervene on a sui^ical Intcr- 
venlion there often exists a neighboring suppuration, whieh may 
pn»vent the insertion of the suture. Wc must wail until the 
6stula ceases to diminish sponlaneously and the tissues have 
taken on their normal appearance and there are no pathological 
secretions in the neighborhood. 

We will not be able Id o]>erate Ijefore llic sixth or tenth week; 
iu general, the patient:* themselves decide tardily for an operation. 

If an operation has failed wait two or three months before 
de<^ding to do a second operation. 



II. Pn •operative TreatmeDt. 

The first point is to treat the vagina and the bladder. If we 
have incrustations of Iimc, ulceraleil or gramdalcd surfa<H's, we 
must cure these, and modify the alkalinity of the urine by repeated 
injected hot boric acid, and afterward *lrj'ing the vagina and 
vulva with tamjjons of cotton wool held in forceps and then 
applying nitrate of silver to the ulcerated surfaces. If at the 
same time as the communication with the bladder there exists 
a reclo>vaginaI fistula do away with the latter, so as to avoid 
infection from the intestine. 

Wien the vagina is constricted l>y cicatriees, commence gradu- 
ally to dilate, doing n'])eated lamjMjning with antiscjitie gauxe 
or by introducing a series of gradually increasing aluminium 
baits. Continue the dilatation luittl we no longer find any 
cicatricial band pmjecting into the vagina. The resistant hands 
should be severed under visual control and m'th great prudence, 
|>articularly those which b<)rder on the rectum or posterior fornix. 

'lliis preliminaiT dilatation which the American surgeons, 
Sinut and Bozeman, have so well studied is still jiraelised. hut 
rejected by the majority. It is (piilc eerlain that it gives a good 
dilatation and that it leads lf> a relaxation of and at the s;iine 
time a freeing of the edges of the fistula in that we do away witli 
the retraction of the cicatricial adhesions which draw in opposite 
directions, hut is difficult and painful, re^juin's some weeks time 



VESICO. VAGINAL FISTULAS 



oOl 



and leads to an injui'iou.s maceration of Uic vagina. It does not 
give any Iwtler results. Personally we have never had recourse 
to it. 

On the contrary, there is oo discussion on the necessity of 
treating the lesions which may exi.st in the urinary system, and 

Ltreat the pus in the urine which is a cause of non-union and of 

'dilating the possible strictures of the urethra. 

The preparations of Uie operation arc not special; give a bath, 
purge and shave the vulva the day before and once the jmlicnt 
is anesthetized do a final cleaning u]) of the vagina. 

III. Operation. 

General Technic. — The position for operation is a matter of 
much discussion. American surgeons have recourse to tlie lateral 
or genu-pectoral position. We prefer the dorsosacral one. The 
imjiortant point is expose tfie ^stitla well. We do this vnth 




Fio. SSS.^Vngitial sprruliim. 



varitnis retractors and draw down the cer\ix when possible to 
the vulva and in stretching the walls of the vagina around the 
fistulii with Museux's forceps (Kig. 389). 

If the listuln is inaccessible because of the cicatricial bands 
we should not hesitate to incise thetu, doing, if necessary, a 
splitting of the vulva or even the j)aravaginal incision practised 
by Schuehardt.' 

' Mkhuux adviMH in um* of Gitulu dlunted liiRli up to do kh (icliio-rvctAl Indalos 
pwaltel to uiid m ffioA finxtr'a breadth frooi the iptiiriuttat finft. TIuk inciuoii OMn- 
meaoes behind at tlii? Irvrl itf the aiiiin and U dlroct«d (oriisril for n 1t>n|[th i>f nhout 10 
on. (3j iiii'lii')-) jiisl to Ihi' point wliorv the incbio-pubii: arcli tuid iJiv liibi* major* 
tnMt. Sepiirul<> iIil- Udiio-rratnl fnt with tho Gnnra and pnua It l»ok lownrti tho 
tulraroKity of thn i»«liium. Thp vHgintt. ptMaed IimIk frith th« finifvt, i> piinctiirini 3 < 
4 om. (It inrliofi) from tlm cervix and the iuoliioii it made gRat« with tlio i 
(Ulehaus, Congrlt franfait dc chimrgU, I8A2, p. 717. 




502 



TREATMEST OF URINARY nSTULAS 



Before Iraciiig llie surface of denudation, it is well for tKe 
last time to determine in which way the approximation of tlie 
[>arL<t with the greatest ease ami without tension is brought 
about. Having done this, without hurrj- and without tearing 
(lie purt.s by druwitig un tJiem too violently, commence the 
itenudati/m- We nnist stretch the parts about to lie cut and 
use a vcrj- sharp knife. Spcfial-curved prohe-pointed bistouries, 
which are often used, are useless and of little vahie; a .scalpel 
with n long handle i.s sufficient. The venous hemorrhage 




FlO, 3$9. — Vewco>va|iiittl fistula ia well rx|>oiM.><l )>v drawinf; tluMrn Uie Mrvix ftiul by 

tnotioii on thi- vdjtiniil wnlls. 

which occurs is of no importance and the insertion of sutures 
sufficeJt to stop it: on the contrary*, if there is an arterial Kpiirt 
put a 6ne catgut al>out the vessel : jterious hemorrhages may come 
on as a result of the neglect of thi.s pn-raution. 

Ill union we use sutures taking up the various planes, catgut 
for the deepest anil silkworm-gut or silver wire for the sutures that 
project into llie vaginii. For suturing in one plane we use only 
non-absorliahlc sutures. 

This small consideration of general technic in the operations 
on fistulas shows us that recent progress denotes a return (o 
simplicity: the <-oinplieated instruments stlU to l>c found at tlie 




VE81C0. VAGINAL FI.STl!]-\S 



503 



makers* are useless an<I the usual inslninieiits are sufficient with- 
out hiiviiifi recourse to special ones. 

Simple Denudation. — Simple dentidation is the most com- 
monly employed procedure. It should he extensive, more than 
1 em. (1/2 inch) and should comprise the vaginal mucous 
memhrune and all the thickness of the septum with the exception 
of the vesical mucous membrane. 



Flo 301 ,— Prabnblu (oElurp owing 
lo tbi' tiiiallit(!w of tho mirrnvc! of rlpnu- 
ilaiioii: pouible incruitAiion* i>ii the 
intra-vcHicftl purtiuu uf Uiu lUt.urM. 




I'lii. aw,- -Too Kmiill a denudulioii, for- 
riod out OD tho vcsicnl miicnun nicmbrnnc 
wid peffonting HulurcH, tThrcp fuiillv.) 



With Ihc scalpel incise the vagina superficially aroun<I the 
fistula. Having done this seize the flap to be removed with a 
pair of toothed forceps and excise willi the scaljjel, taking care 




^r 



Fiu. .303.— l^tL'Tuivc vuic'iul denudaUon Pia. 3M.— The p«n«< &r« wi>11 and 

with tho miturni npproximntmg » Urn oKteut (noly MipraiiinAlM: the sutitrca do 

of liMuc aiitl pmuiiiiii; liolow Uie vesEoftT muooii* not perforat« tlic bliuld«r. 
tnembmnc. 



to eiit the tissues deci.sively and obliquely right to the end of the 
fistula. This denudalion should be complete. If there are any 
non-denuded portions, draw U(M>n thern and excise them after- 
ward with fine curved scissors. 





FlO. 30-4 .-'Ui- II U(]b lion iu >tuir foriiiAtiiiii ibail). 



Fco. 30K. — AfWr tim ili-ntnUliuit 
the pkrln ajiproxunati.' Ixwlly, 



The denudation should be <lone ublicjuely from the vagin:! tu 
the bladder. A stair-like denudation does not tend to a complete 
a])j>r(ixiniation of the surfaces (Figs. 394 and 395). During the 
whole stage of the deniidntion, an assistant with a stream of 



604 



TREATMENT OF URINARY FISTULAS 



saline washes away tlip )>1(k><1 from the field. The denudation 
having been finished a teniporai-y compression with a sterilized 
gauze tampon sufKces to stop the hemorrhagic oozing. 

All tliat now remains is to unite the denuded parts. The 
sutures should pass under the denuded surface, and take up 
extensive and .symmctrieal surface, and should not be too 
numerous, having an interval of 1/2 to 1 cm. as a rule between 
them. 

We must tie tliem sufficiently to bring the parts well into 
contact, but avoid the constriction of the tissues so as not to 
cause them to become gangrcnouii. 



« 




Fia. 306.— SatuK >fi«r denudAtioti. 

\Vc use .shar|)ly curved needles, held in a needle holder, to 
insert them and using a tenaculum sometimes to fix tlie tissues 
while we pass tlie needle. Commence by passing a medium 
suture, which enters the vaginal mucous membrane ulniut 3 mm. 
from the e<Ige of the denudation and apijeara just below the vesical 
mucous membrane and then lak<-H up the lip un the otlier 8idc. 

The two ends of the suture are seized with pressure forceps; 
insert other suturvs afterward and only commence to tie them 
when they are all in position. The union of the denuded surface 





VE8IC0-VAG1NAL FISTULAS 



50$ 



is done in the most favorable sense as r^»ards the approximation 
of the parts, hy following an ohtique curvwl line shaped like a U; 
tlie only point of importance is to avoid lines of sutures that 
cross like an II or Y, etc.; the point of intersection of two lines of 
sutures always constitutes a weak point. 

If the fistula is situated near the neck of the hladdi-r, we iinisl 
think of the ureters and make certain before commencing the 
operation that they do not open on its borders. In such a wise 
we must dissect them a little in order to retuni them toward the 
bladder and be careful when passing the sutures at their level 
not to take up too nnich tissue in order to {)e sure of obliterat- 
ing them. 

When the denuded surfaces cannot be approximated, we 
abotild mobilize the fixed parts. In a case where the fistula 
adheres by one of its extremities to the pubis, Kelly merely intro- 
duces a tenotome tlirnu^h tin- vulva about 3 cm. (I 1/4 inches) 
from the fixed point and by the subcutaneous route frees the 
bony atlhesion. 

Generally we confine ourselves to continuing the denudation 
by a more or less Icnglliy incision and its e<lges are separateil ; at 
other times on a line with the cicatrix we split laterally or else 
we combine these two procedures, i.e., we separate up a flap and 
Uien parallel to it make an incision so as to render the tissues 
mobile. Finally, when the surface of denudation has been modi- 
fied afterward by adding two secondary' denudations to tlie ex- 
tremities of the ]mmary denudation suture these latter so as to 
approximate the parts at their level antl to have in Uie center, at 
the fistula, the tissues approximated without tension. 



i 



&= 



:ic 



Kia. 397. — dc Pcuor'* calJiet«r. 



Wlien the operation is finished, we tampon the vagina lightly 
with iodoform gauze and leave in a catheter. The best thing to 
do is to ii.se a th* Pezzer's catheter, which is easily intrcHluced into 
the female urethra and which remains in good position without 
any need of being fixed in. If one does not possess this catheter, 
use a simple rublx^r tulic, which is introduced after an injection 



500 



TREATMENT OF URINABY FISTULAS 



of borac'ic acid into lliy bladder, until the fluid flows out of llie tuber 
llie tube at this moment projects just beyond the sphincter; fix it 
to the meatus by a suture to hold it in good position. Leave the 
eatlicter in for about a week and give the patient about 20 
grains of urotrnjiine daily; wash out the i>hiddor daily with a 
feeble solution of silver nitrate (1 to 1000) if there is pus in the 
urine. 

The sutures art* taken out progressively from llie tenth to the 
fourteenth day under visual control; always press the fourchetle 
(l<»wn with a Sims' speruluui. If one does not see them clearly, 
feel them gently with the finger, so as to determine their situation 
at once. 

Splitting. — Denudation by splitting of tissues may be done in 
two ditl'ercnt ways, either imKHHiliug from the Kstidous orifice or 
in proceeding from an incision encircling the fistula and passing 
alwut 1 i/i cm. outside the incision. 

I. DenuiUttion hy Splitting Outward from the Fistula. — De- 




FiQ. 398.— Donudfttion by Bplltting outward Fio. 309.— Siitiini after •putting, 

from the fiatuu. 

scribed by Gerdy in 1841, and then abandoned in favor of denuda- 
tion, this procedure was taken uj) again in 1804 by Duboue and 
then in 1896 by Phenomenoff. llicard' and others, .\round the 
entire circumference of the fistulous orifice at the union of Ihe va- 
ginal and vesical nuicous membrane arul in the cicatricial tissue is 
made an incision which is prolonged on each side into tin; vaginal 
mucous raenibraiic. It is then easy lo split each of tlie lii»s, in 
cleaving its vesical ancl vaginal walls over a variable extent of 
1 to S cm. (Figs. 398 and 3!)!)). 

Having done this splitting at the base of the wound we see 
the freed bladder, limp and RtNiting around the fislulou.H orifice. 
Close it with a line non-|>erf orating, purse-string or continuous 

■ llip«r<l, Cimgria/ruH rfr thir.. Parit. 18S6, p. 927. 




VBBICO- VAGINAL FISTULAS 



607 



catgut and then suture tlic vaginal flaps above, l)eing eareful to 
pass the sutures through their base on a level with the dehedra] 
angle resulting from the splitting (Fig. 400). 




Ir'ta. 400.- 



-Suturt! ikfter splitting oulwnrH frnin tlic flutiJa; Uie vcscal muooui mom> 
brnnc is united : t.lie vngiiial niilurM ure iniierttHi, )nit not Ucd. 



2. SpliUiti^ Outward from an Inchion at a Distance from lite 
Fiffiihi, — lIrH«)uchaye' makes an ineision at a little distance from 
tlie fistula. The incision encircle.s it and then splits the ve.sieo- 
vaginal septum in being directed from the incision to the fistulous 
orifice (Fig. 401). 



? 



PlO, 101.— SpHUJnff bj- AD incision maile 
at a diHtanci;. 




l-'i(i. 402. — Suture of the under «ut 
vbmIo&I muoow oicmbrtiiie. InKortloD of 
vaginal auturw. 



We mu.st make a circular incision 7 mm. above and 12 below 
the fistula and then cli-iscet iij) the islet of mucous membrane of (he 
vagina, thus circuuiscriU'tl to « ithin 3 or 3 cm. of Ihe etige of the 

■ Bntquoh(L}-r. Cong. /ritnr«>« <>< Chir., Paria, IdW, p. 050, «t Bull. M Jif An. (b la 
tSot. lit cAiV., Puri*, leoO, p. M8. 



008 



THJiATMENT OF URINARY FISITILAS 



Bstula. Wp have tlnis a collarette of mHcous membrane adiicrcnt 
to the fistula itself by a circular pedicle. This collarette is turned 
back into the fi.stulou.s oriBcc in such a manner that its mucous 
memhraift surface faces the cavity uf the bladder and its raw 
surface the vagina. Suture it together with fine calgul. Then 
insert the vaginal sutures, burying the collariHle lliat was ]>riruarily 
sutured (Figs. 405 and 403). ' 





PlO. 403. — Butuiw aTtitr ■pUtiinic hy nn incurion at n (tiftKnco; tho oaUarett« of mucoua 
BMBLbrane i« ptuihpd liuok toworil t)i« bliultler by acniiciit |iurt«-«trinKiutui«: the vhkidaI 
autuiw ara ln»crt«ii. tint not upii. U they ure ticil ilie 1iul> of thr VKgitul lUiiOD will be 
posteriorly situatol (o Iho bliuUldr niturn bi-aiiiBo uf tho Asymmetry ol the ptim»ry 
indrion. 

The closing U so much the mure certain if the original 
circular incision does not pass at equal distance from the borders 
of the fistula and tlius in consequence the two lines of suture do 
not carrespon<l. 

We have found this procedure very practical for closing 
fistulas situateil at tlie far end of an infumlibuhini; we have 
thus cured fistulas with the greatest facility which hqd followed 
on vaginal liysterectninies. our colleagues having vainly attempted 
to close them bv other means. The incision is made anteriorly 
to the fistula, which lies at the far end of the cicatricial tunnel 
and which corresponds to the vaginal fornix. The operation is 
simply carried out afterward. 




VESICO-VAOINAL FISTtlL.Ui 



609 



Treatment of Fistulas Situated in the Neighborhood of the 
Cervix Uteri. — When working nrar a rigui cervix wliose tissues 
cannot be placed in opposition like those of the vagina ami when 
confroted wilh a fairly long fistulous track, wc must deal with 
it in a special manner other than simple denudation of the vagina. 
From an oval incision encircling the fistula, branch olT at tlie level 
of the junction of the vagina and cervix with a transverse incision 
an^I then split the vesico-ulerine septum until the upper UmiU 




Fia. 404.— Drnundntion of u fistulm ngnintl the cotvix uteri. 



of the fistula have been passed. Then completely excise the tract 
of tlie fistula, sutun* the vesical and the uterine gaps separately 
and terminate by closing the vagina (Figs. iUi and 405). 

Operations in Several Stages. — Sometimes one fails in the 

treatment of a vesico-vaginal fistula. Fritsch advises then to 

.make the line of denudation of the second operation perpendicular 

that of the former o|ieration, and to tie the sutures so Uiat 

le tno sides of the old cicatrix do not correspond to each other 

[(Fig. 406). The operation in several slage.H may be done delibcr- 




610 



TREATMENT OF URINARY FISTULAS 



ately. It is that in presence of very in-egular fistulas there "is 
often an advantage in not Ir^'ing to obtain at first a doMure uf 
all the fistula, but to confine oneself, as Fntscb docs, to suturing 




Vta. 405. — Suturv tJlvt oxcisiou of a Gmuloua tract. 




fio. -100. — Ucnudnlion and suturv ot n fiatula in a dcntrix of ft tpnn(<r optinUoA. 

one of its prolongations, and only to close* tlie remainder a month 
afterward, taking care that the second suture is in a sense pei^ 
pendiciilar to the dircclioii of the jwrts already united (Figs. 406 
and 407). 




VESICO-VAGIXAL FISTULAS 



511 



Special Procedures Applicable to Large Losses of Sabstanc*.— 
If Ihi' fistula is vm- wi«l<; iinil tliere arc at tin' siiim- tiiiit' extensive ck-iilrice* 
of (he vnginnl wall, tlic procedures we have jubI described arc insufficient. 
It is inipoHsihlc to apjiroximale the edges of such an extensive an-a. where 
generally the suliin-.* cut through nnd the wound reopens. 

Flapn. — In the case of a hniftd fixlula occupying ahiinst the whole extenl 
of the vcsico-vapHul septum. A. Martin' makes a few incinion.* in Uw 
VBginnI mucous mcmbrnnc n1 a <-«Tlain distance from the fistula and parallel 
to it. which enable him to free the vagina while working toward tlie fislwln; 





Fio. 407. — Partial obliteration of « pro- 
loBi^tJaii of til* fistula. 



Fid. lOS. — Tlie nrolonution is cIo«o(I. 
I >i- II 11(1 a I ion aud nituiv »( nliat rcmiunii of 
\he fistuln. 



the two flaps thus incised arc directed toward llu- bladder anil (hen sutured, 
while the viiginal u-oumU an- unilcil afterward in a cnljwrniphj . 

Trendelenburg' suliircs a li(tr«e-.>hiie .'•Iiujiti) (lap lo the luleml and inte- 
rior edgeii of tlie fistula. This flap is detached by tliree of its sides ftt»m the 
posterior wall of the vagina. He doe--< u second stage, four weeks later, nnd 
cuts the |icdicle of the flap nn<l fixes it to the po.steHor part of the denuded 
Bstulo. 

Odcnthal* cuts two lateral flaps having their pedicle at the level of the 
fistulii; lie directs them toward the bladder mid Ihen sutures them. 

Fritsch advises the operation to be done in the following inauRer: he 
freshens the fixed edj;c of the fixtula nn<l then files the mobile edge hy 



> A. MarUii, 'IrilKh. /. 6>(i. and 6V<-. \>i'i\. No, lt>, p. 3H. K 
eu KCfiiiTK A lu tuWie tic lomticaux vaKi"*")' "" VDidaa^O do ta 
Brrl. Ui'i. H'orft , IHHJ. Xo. 31). 

■ Tr^iidfbiitiUf^, .SiintnJ. klin. lI'ocA., 1890. So. 355. 

■ Udenllial, Cmir.'BI./.Gpt.. Aug. 17. 1001, p. M5. 



lor avail di'ji'i 
(Uydygier. 



4 



512 



TREATMENT OF URINARY FISTULAS 



cutting a flap much largi^r than would be rcquiivd to fill the orifice and m 
thick Its ii(Ks«il>Ii\ This flap is drawn owr thv surface to be eovenNl. 
It is lixed by a primary row of fine catgiiLi uniting ite d«c)> surface; the 
HUiK-rficia] siitunrs rihould exercise no traction and arc only inserted if the 
flap has a tendency to b<; disJ)lacl^d. 

Liberalian of the Bladder. — Described and carried out by Jobcrt under 
the name of ve-tical aulopla^ty by "glissemeiit ou locomotion," tli« rendering 
mobilv of the bladder has latterly been utilized by a certain number of 
flurgeon.s. E. C. Dudley in one case mobiHeed the vesical mucous luembrnne 
behind the fistula, and then sutured it to the anterior part already denuded 
on its vaginal surface. 




Flo. 400.— l-'replDs: o( tlie bUttdur. By an 
ineinon wo Kplit tha vwiao-iitorin« oopluin 
aloiiK tlic whole longth of ij/'. 



Via. 410. — Ths blxliler liaving 
liocn fr<H*d the Ion i>[ iiihclanm) ia 
ilonc itwuy nitli by i)i«' edsri l>niiK 
nuturp(I;/is now in couioot witti/'. 



^faeken^odt ' makes a lonji! meilian incision in the vaginal wall, extending 
in fnuit of and behind the fUtula, and tiien he .^pliLs tlie ve.sico- vaginal septum 
laterally and a ntero- posteriorly. He carries out this separation of the 
bladder, if nccesKury, a.-* far lut tliv vevico- uterine fold. Having thus fr«ed 
tlie entire liaseof the bladder, lie is in apposition to suture it as in thcdiagrnni. 
by uniling the edge.i of the luits of substance. The vaginal wound is after- 
ward closed and the uterus drawn down and if neces.sBry it is used to close 
the (lerforntion. 

■ MaclcenTudt, Ctt\tr.-ftt.f. Gfn., Lolptifc ISH. No. 8. p. IWK 



4 
I 




513 



Kelly* has rpcourse to mobilixalion of the hladdcr. He makes a crc«»nl- 
iibii|i<'il indicion behind the Rsliilu and ^cparatcx the [tnrt in front nt the vagina 
and cpFvix uteri. 

The danjfor <rf thc-te iipiicedurcf of veiticnl mobilixatioii is the |>os»il>ility 
of injuring the uterus, which Is sometimes displaced bv cieatricial retrac- 
tinnx. 

VUUzing the Vtenia. — Freuud* has used llie body uf Ihe titenu. in 

order to cIomc largff fistulas, tlie body of the uterus Mttaehvd in tlie vagina 

after posterior colpotomy. The uterus is fixed as in the o[>eniti<]n for 

"BaM'ult:" of tbi' iileruM where it in drawti down into Uie vagina uiid 

6xed with the fundus below. 

Ori'limliin with the Airli-ri'iir I.iji nf the r^rci>. —Wi>lk(»wilseli and Kustner 
detached the cervix and drew down the uterus and then after cxeisiuii of Ihe 
cicatricial ring eneirdinfr ihc listulii, stiippcd it up by uniting it with the 
denuded cervix. 

Otvluswn u-ilh thr Pnslrrinr Up of Ihe (Wrix. — In certain fistulas invading 
the cervix, its anlcrior lip may be wanting completely and in such a cane we 
Hiitiire the posterior lip of the cervix to the edges of the fistulous orifice. 
Menstruation occurs by the Madder and results in no inconvenience. 

(hrluitiim with Die Vegiciiutirinv FrriUmfum. — Bunim and DOderlcindoa 
hysterectomy, and then use the vesieo-uterine peritoneum in order to close 
the listuhi. Ilardescu draw.i down the vesico- uterine peritoneum, but 
without doing a preliminary hysterectomy and confine themselves to doing 
nil aiili-riiir colpotitniy. 

Aidocyniaplastij and Coljwrifstoplavli/. — VroSling by the fad that mucous 
ineiulirmif nf ihi- nntero-siipfrior wall of the hl(i<lder often cail-«-« ii hernia 
into the vagina through the ti.'itula. Wit/el' simply denudes the hernial pro- 
trusion of vesical niucou.t ineiiibnine and KUlures it to ihe lip of the denuded 
fivtuln. This operation had the inconvenience of definitely preserving an 
abniirinal eoiidition. I'.r., the jirohipse through &stula and of partitioning 
the bindder and of leading to injuries of the upclor. Witnel abandoned it 
for an operation which is almost the opposite. By a suprapubic inei.tion 
he scire* the posterior wall of the vagina through the fisliila and draws it into 
the blu<lder, ilennde-s its surface and fixes it to the fresheni.-<l edges of the 
fistula. At a second stage and after perfect cicatriKution, he separates the 
part of the vagina fixed in the bladder from Die vaginal canal, which is then 
reconstituted Ity suture. 

Suprojntbir tucixiim.- Trendelenburg' places the patient in the position 




' HowanI A. KeWv, Johnt Hapkina AtiUrn'n, BftUimom. Feb., tllH. 
•Fwuml, W, A-, .S'liHinif. klin. Wvrir.. 1895, So. It8. 
' WiUrl. Ann. ilf Gun.. ParU. lOOI, T. I. p. 284. 

' Trvndeleiiburg. L'l'licr U1ii»nniicli«i<lcDflM«Iopcrai)iiiM>n udiI Utwr Becltfitltodilau- 
rung boi U|jfrntioncii in ilor IlaMc)iliOllla. Sommi. klin. Wonr., MpaiR. 1K1HI, No.3»S 
33 



*r«->riat4ui -witii iiirt aame aati tbea does a tzans^^se lafoapabK incision and 

'Ait pmrKKrinuz Eie f wj h eiig tlif fiftoln swi tb^ Mibues ft with suluica 
ha-riiu- a luwHlft timwiaf to ea«:k end m t&ot tfae twn eiiieiuitin may ap- 
p>»r in thft tscuia ami aie tin! in dot canaL 

C'iijir^Uw. — -MtKT amfit eoipodesB or occiiB»wa ai the Tsgina,* he 
hiriniEi »>jont a ^ta^taatirMi n/ miiK in the vatEinal fornix which has now bvcome 
« 'li^ftrtimhnD ol the hlaAh r Ths lemb to the fonnatian of pbosfdiatic 
f^airiili wIwMe rfiaMnaHMfci but beconMr n>n cottttdnabfe. 

T^ paiiM [>>a<l to a destrartioa of the wctom focnwd and things are 
n^^>rM to tbnr former state. Howevvr. better technie in the treatment ol 
VH^i^t-raeinal Eitalas haj caodcd i» to abandon tht« method of treatment. 

There are, however, ca^eswfaeie the meter had been destroied at the same 
time a/t the nnio-Taguial septum and where the attempts at its restoration 
arK or>iMtantlT foDowed bf faihtte. Fritsrh adn»s a cranbtnation al a recto- 
vaii^nal fistala with a colpodesi^. 

The important point i^ that there *bould not be anv stagnation at oiioe in 
the Tagina. To avoid it. make the reeto-vaginal fi:<tula as low as possible, im- 
mt^iately above the .«phineter. and incite the pait^ transverselT. which resuhs 
in the production of a fold of tertal mnroo^ membrane serving as a valve. 
Then exri.te from the vagina a ring cf murou^ membrane, and dose it by a 
uj^ttal suture. Diminish ad much as possible the capacity trf the vagina, 
and denude in an oblique direction, so that it terminates exactly at the 
re<ft'>- vaginal fistula, and no cul-de-sac lies above it. 

Ch^nieux' combines, in certain urrthro-vesico- vaginal fistulas an epu* 
rorraplttf with a hyp<^astric meatus. 

i. Vesico-titeriiie Fistulas. 

Vesico-uterine fistulas have been treated either by direct or 
indirect obliteration. 

Direct Obliteration. — By a transverse incision is brought 
almut the separation of the cervix uteri and the bladder. The 
.scjjji ration is continued for a ver^" considerable distance round 
the fistulous opening. The edges of the bladder portion of this 
arr tlien freshened and sutured. 

The uterine portion of the fistulous passage is excised and 
snhircd. Tliis done, the cervix is fixed anew to the vault of the 
vagina.'' 

Dittt'l, then Forgiie, have had recourse to the transperitoneal 

' A, h: l)»iihl(r. Dii KldHJHRenitalet prindpslemeDtderoccluiiioa vogiaalect vulvaire 
iliktiK l.'H (iHt.ulr^H iiro-itr'nitiilcs. Th. de Paris, 1876. 

■ flirnicnx, /{'■v. lU- gyn. el Chir. AM.. Fang. IflOC. p, 21. 

' IfiHI, 7.1-ii-eh.f. Oii. u. 6'yn., StuttRart, 1891, T. XXII, p. 1. 



VKSI CO-UTERINE FISTULAS 



515 



route.' After an incision of the u tern- vesica! poucli, cncroftch- 
ing on llic anlcrior surface of tlie broad ligaments, the bladder 
is carefully separated from the cervix till the fistula is reached, 
which is then slit across, and any fibrous masses present are 
excised; then the edges of the fistula are freshened. The fistulous 
openings on the vesical and uterine sides are sueeessivcly sutured; 
then the utero-vesical peritoneum is replaced. 

Indirect Obliteration. — Indirect obliteration is very simply 
obtained by denuding and then suturing the lips of the cervix 
(hysterocleisis). Menstruation then occurs through the bladder. 

3. Utero -vaginal Fistulas with Destruction of the Urethra. 

The Ireatmcnt for small fistulas is the same as that of running 
vesico- vaginal fistulas; but when there is almost complete destruc- 
tion of the urethral canal, an auto|)lnstic operation must be 
resorted to.' cutting flaps at the expense of the vagina and vulva. 
In some ea.<)es it has Iteen p(Kssib|e to use flaps from a persistent 
part of the utero-vaginal septum. 

We cannot describe all iJie various methods of procedure here 
they are so numerous. 

Fritsch makes an incision on each side of the urethral gutter, 
se|»arates the urethra from the vagina, folds it in on itself, and 
then covers it with the separated vaginal wall. 

lYan cut two vulvii-vaginal flaps and folding them over toward 
the middle line sutunng one to tlie other. Urns reconstructing a 
uri'thral canal; he then marked out a (1ii]> on each side sufficiently 
large to cover over the bleeding surface left by tlie last flaps, at 
the same time replacing the lo.ss of substance their removal had 
caused. For this purpose he dissected freely from within out- 
ward the integuments of the vagina and vulva, till it was pos.sible 
to bring the inner borders of the flaps in etnitact by sliding llieni 
up, and then he sutured them together. Thanks to the laxity of 
the tissues in this regi(m, this second part was easily performed. 
lie sutured these two flaps a little out of the middle line, so that 
there would not \te two layers of suture lying together, one 
superimposed directly on the otlivr. The operation was fuiished 

' ForKXii^. NevuK de gynUolosie » ehirurgit abdominalr. Parin, 1006. p. .S03. 

' l>lbr€cgui!. Dcl«r<;iitnurntioil(l«rumnciiCili>ri.-inm<r. r'l.rf* Pari*. ISIK, No 283. 
Colturd. TrftiuiiPnf op^ratoirv do riDoontlncode d'uriiu) obc« U loinme. 
0. Stein)iL-i1 lOOU^lWf, No. D3, 




516 



TREATMENT OF CRIN'ARY FISTULAS 





FiQ. 411.— iQcision for vulvo-vsgioal flaps. 




Fio. 412. — 'The Haps arc foliltMl over to form a canal. 



VESICO-UTlilU.VE FISTULAS 



dl7 



by the union of the anterior borders of the flnps surrounding the 
new meatus (Figs. 411, 412. 413}. Others have roinineiiced by 
forming a canal on a level witli the vestibule and then have fixed 
to the posterior borderof this new urethra a flap cut at thccxiK-nse 
of the ve.sico- vaginal septum and brought acrass. 

Noble has ingeniously modified this part of the operation by 
dissecting a broad strip of tissue on tlie anterior wall of the vagina. 




Fio. 413- — The raw «ur{acos are covered by the sliding up of Utrml flaps. 



having its apex downward and its Iwise at the level of the vesico- 
urethral opening. With a pair of forceps introduced through 
the canal lie has made, he ilraws this strip through, anil fixes it 
with fine silk to the new meatus (Fig. 414). 

As the leaving in of a catheter and catheterization are often the 
cause of nonunion, Frilscli ad\'ises bladder puncture and the fixing 
in the perforation of a small catheter till the flaps have united. 

\^'hatever method has been emph)yed. a complete continence 
of urine can hardly be expected : one can remedy tliis by the use 
of a pessary with a suburethral pad, which pre.<isi>s the walls of the 
new urethra together and hin<lers the outflow of urine. 

In inoperable cases, the juitient is condenmed to the carriage 



i> TEEATXEST <* CRIXARV Fl^rTLiS 

tA a urinal or to a ctJpodesU with a rectal fistula (h* a hrpt^astric 
rrritototnT. 




Fig. 414. — Cloaing of the urethro-Tvaical orifice. 




Fio. 415. — ^Urinal. 

4. Fistulas of the Ureter. 

Fistulas of the ureter are the result of traumatism either dur- 
ing labor or more often now-a-days during gynecological opera- 
tions. 



FI8T11LAS Of THE URETER 



519 



Prophylactic Treatment. — ^Aii exact ktunvlcdge of the course 
of the mvler. and the employment of well arranged proceedings 
in an operation, so avoiding a lesimi of (he ureter. If, however, 
in the course of an operation, a lesion of this eanal is discovered. 
it must be treated immediately. 

We refer to a former work for the study of the various metli- 
ods of dealing with this condition.' 

Curative Treatment. —Fistulas of the ureter may heal up 
spontaneously; thus some which are kept up by the presence of a 
ligature and Hiksc up dirc<'t!y this is removed. This cicatrization 
is only obtained, liowever, in eases where the loss of substance is 
restri<-ted to one [)arl of the circumference of the canal. Speaking 
generally, a fistula which lasts for more than six weeks gives 
ven.' little hope of spontaneous cure. It i.i then necessary lo 
have recourse to a surgical operation; beforehand, all that is to 
W done is to insure as complete asepsis as possible of the region 
of the fistulous opening, and to treat, if it oc-curs. the (H>neomitant 
cystitis, the danger being above all the pyelonephritis that may 
result. In the presence of a fistula of the ureter, the surgeon 
possesses a series of methods of treatment which may be classed 
under three heads: first, plastic ocTlusion; second, ureteral griifl- 
ing; third, nephrectomy. 



I. Plastic Occlusioa. 

Tlie first attempts at plastic occlusion were unsiicces.sful, and 
it was not till the work of X^andau that healing of ureteral fistulas, 
after a simple plastic operation through the vagina. oci-urre<l. 

Landau distinguishes the eases where the vesical end of the 
ureter is permeable and those in which it is impermeable. 

If Ihe vesical end is pernu'able a catheter should be intrcHluced. 
one end going toward the kidney, the other passing down through 
the bladder and urdhra. Ix'aving thecalheler in i>Iace, the edges 
of the uretero- vaginal opening are freshened and then united by 
several sutures. If the vesical end is impermeable, an incision 
is made along it till the blutlder i.s penelratcil. From each side 
of this incision, a certain quantity of vesical and vaginal mucous 

> HartniAOD. Cliiriirgie ilci ofgknn giuito-urin^ro* de rbomme, Pkri*. Q. Huinliril, 




520 TREATMEXT OF URISABY FISTTIAB 

membrane is excised, thus creating a Tesico-raginal fistula, in 
the form of a very elongated ellipse into which opens the ureter, 
at its supero-extemal angle. The wound is then united. 

Pozzi, ' in a case of lateral fistula of the ureter, has employed the 
method of splitting. After having passed a ureteral catheter, he 
made a transverse incbion at the level of the fistula; at the extrem- 
ities of this transverse he made two longitudinal incisions, giving 
to the whole the appearance of an H lying on its side ( S ). After 
ha^-ing cut the two flaps thus circumscribed, he brought them in 
contact and sutured the one to the other without the least diffi- 
culty. 

Mackenrodt," whose method of procedure has given a certain 
number of successes, circumscribed the fistulous opening by a 
circular incision and dissected out the extremity of the superior 
end furnished thus nith a collarette, which he fixed to the vesical 
mucous membrane of the bladder after piercing it and introducing 
the expanded end of the ureter. Then he shut the vaginal wound 
Ijy two layers of sutures. 

Sellheim, in a case of bilateral fistula, where the two orifices 
opened into the bottom of a tunnel, made a vesico-vaginal fistula 
at this level; then, in a second operation, he sutured this fistula 
to the borders of a raised flap. The fistulous openings thus 
opened into a small vaginal diverticulum in communication with 
tlie bladder. Segond did a similar operation, fixing to the re- 
freshed border of the vaginal fistula a flap cut from the base 
of the bladder. 

II. Ureteral Grafting. 

During tlie last few years jihtstic oj>erations have to a great 
extent been replaced by ureteral grafting. Numerous methods 
of doing this have been recommended.^ 

The operation of Mackenrodt that we have described in 
connection with jilastic oj)erations is. in a way, intermediate 
between plastic ojx'rations and vaginal grafting by the vaginal 
route. 

Oilier nu-thoils of vaginal grafting have been enijjloyed, but 

' I'lizZL. Hull. .1 Mem. ih- III .S„c. ill- fliir.. I'itHs. 1SK7. T. XIII, p. lU, 
■ Mui-ki-iLriNll. 7,iil'i-h./. (lih. 11. Hjiri.. SliiKciirl, IMM, T, .\XX, p. 310. 
' l.iitiiinl, rri''l<'Tii-i'Vnlii-rii''ii,itiimii', Th. lU- I'iiiik, lyil". 



riSTULAS OK THK L'RETliB 



621 



now-a-davK there is a tendency to ahandon all these operations 
tlirouKh lilt' viigiim and to do all cases of utero-cystu-neostoniy by 
the abdoniinni route. Tliis latter opi'ration has sometimes been 
done by an extra-peritoneal route, but in most cases theinlra-peri- 
toneal method is to be jireferred. 

After a median celiotomy the ureter is sought for, and is 
usually easily to be foimd, as it crosses the brim of the jjelvi.s, an<l 
is then followed downward. Tlic peritoneum over it is incised, 
and it is dissected nut a little so as to render it movable: then it 
is cut across above the fistula and implanted in the bladder, which 
has been forced uj) by a metallic sound. 




Flo. 416. — KvUtionK of the ureter M the brim of Uio jwlvl*. 

An incision of a centimeter and a half is made in the bladder. 
A loop of catgut having liccii jiassed through the ureter, at a 
certain distance from its section, its ends are taken and one is 
threade<l on a needle an«l passed thmugh the bladder wall from 
within outward at one extremily of the incision into the bladder; 
then the oilier end is similarly passed through the other end of 
the incision, then by drawing on each end the ureter is invaginaled 
into the bladdt-r (Fig. 418). In order to insure the free flow of 
urine, a sni]) should be made in the wall of the ureter opfiosite 
that carrying the Ioojj of i-atgut. The bladder is then shut by 
two layers of sutures (Fig. 419). 

Kicard has o|)erated recently iti nither a dilTerenl manner: 
after having split the end of the ureter, he turns it buck like the 



522 



TREATMENT OF URINARY FISTULAS 



cuif of a coat sleeve, and fixes the mucous membrane thus 
turned up to the adventitia by two ligatures of fine catgut (Figs. 
420 and 421). He opens the bladder with a bistoury and in the 
small incision thus made pushes 1 1/2 to 2 cm. of the ureter 
into its cavity. The ureter, of which the extremity hangs free 






Flo. 417.— A loop of 
catgut through the uret«r 
with the extrcmitieB 
broueht through the 
bladder openine and out 
again thTouf;h tne wall. 



Fig. 418. — The 
ureter drawn into the 
bladder to be fixed by 
kDotting the ends of 
the cat^t. 



Fio. 419.— The 
bladder wall \b sutured 
round the invaginated 
ureter. 



in the bladder like the clapper in a bell, is fixed by a ring of 
catgut sutures which pass through all the layers of the bladder 
wall save the raucous membrane on the one side and the external 
and muscular walls of the ureter on the other. A second layer 




Flo, 420.— Fig. 421.— 
Ureter with Ureter with 
cod BpUt. end turned up. 

of sutures, also of catgut, are placed above the first, so as to 
bring at least one centimeter of the walls of the bladder and 
ureter in apposition (Fig. 422). 

Payne' splits the inferior extremity of the ureter for a length 
of several millimeters; this forms two valves, which he fixes on 
each side of the vesical incision. 



Payne- -^^ of Amer. Med. Aegoc, Chicago, 1908, p. 1321. 



FISTULAS OF THE URETER 523 

In all cases, in order to avoid traction of the bladder on the 
ingrafted ureter, it is advisable to 6x the bladder to the pelvic 
peritoneum by a strong suture, attaching it in front of the ureter. 



Fia. 422. — Sagittal section of the invaginated ureter. 

III. Nephrectomy. 

Nephrectomy is indicated when the kidney corresponding to 
the fistulous ureter is unhealthy, showing signs of pyelo-nephritis. 
It should only be practiced, however, if a preliminary examination 
of the functional powers of the other kidney shows this to be 
healthy. 



INDEX. 



Abdomen, ioapectioD of, 7 

physical exanuDation of, 1 
Abdominal celiotomj', 293 

general technic of, 293 
operatioQ for, 299 
preparatory measures, 293 
operator, surroundings, patient, 
preparation of patient, 296, 297 
compresses, 93 
cystopexy, 412 
hysterectomy, 329 

for cancer of the uterus, 357 
indications for, 360 
operation tor, 361 
modification of operation, 369 
CO mpli cations, 371 
albuminuria following, 372 
lesions of ureter following, 372 
results following, 373 
for fibroids, 434 
for fibroma, 349 

indications for modification of tech- 
nic according to the nature of the 
lesion, 347 
for inflamed adnexa and fibroma, 
349 
results, 349 

extraction of fibroma, 350 
indications for total or subtotal 
hysterectomy, 351 
for inflammatory adnexa, 349 
results of, 349 
type of procedure in, 329 
various procedures in, 338 
operations for displacements and 
deviations of the uterus, 393 
aome rare, 407 
myomectomy, 432 
palpation of the ureters, 478 
Absence of vagina without complications, 

129 
Acid, leucorrhea, treatment of, 121 
Active electrode, 75 
Acute adnexitis, 423 

dilatation of the stomach following 
celiotomy, 325 
Adhesion of the labia, treatment of, 107 
of the prepuce of clitoris, operation 
for. 106 
Adnexa, inflammation of, 381 
neoplasms of, 382 
removal of, 37S 

treatment of, inflammation of, 422 
removal of healthy, 378 
vaginal hysterectomy in inflammation 
of, 2G5 
Adnexilis, acute, 423 
chronic, 423 



Amenorrhea, 465 
primitive, 465 
secondary, 466 

use of continuous current in, 81 
use of static electricity in, SI 
Amputation of the cervix, 184, 189 
with the gal va no-cautery, 190 
with the knife, 190 
of clitoris, 110 
Anatomo-pathological lesion of prolapse of 

tne uterus, 446 
Anatomy of the supports of.the uterus, 444 
Anesthesia, use of in gyaeeologi(»tl exam* 

i nations, IS 
Angiotripsy, 260 

Anteflexion of the uterus, congenital and 
required, 453 
Nourse s operation for, 195 
Reed's operation for, 194 
Anterior abdominal hysteropexy, 393 
operation, 393 
results, 396 

indications for, 398 
colpoceliotomy of Doyen, 229 
colporrhaphy, 162 

combination of, with amputation of 

the cervix, 167 
precervical, 167 
various procedures tor, 166 
colpotomy, 219, 233 

immediate result of, 230 
incision of vagina in, 220 
modification of t«chnic according to 

the case, 222 
opening of the peritoneum, 221 
operative technic of, 219 

separation of the bladder in, 221 
Wertheim-Schauta's, operation for, 
227 
Appendix, 18 

Application of medicated bougie and of 
caustics to the uterine cavity, 45 
Atmokausis, 48 

complications of, 50 
indications foi', 51 
technic of, 50 
Arcus Fallopii, 13 
Auscultation, 9 

Baldwin's resection of the pelvic colon, 135 
Baldys' operation for shortening the round 

ligament, 403 
Bartholinitis, treatment of, 104 
Bartholin's elands, cysta of, 117 
Baxcule of the uterus, 217 
Benign tumors of the vulva, ti««tmeiit ot 

112 



525 



526 



INDEX 



BeuttDCr's modification of abdominal 

hvste recto my, 348 
Bier'a method for producing local hyper- 
emia, 52 
Bimanual examination, 11 

with the pelvis elevated, 14, IS 
Bladder, bimanual examination of, 475 

catheterization of, 475 

curettage of, 494 

cystoscopy of, 476 

examination of, 475 
vaginal, 475 

foreign bodies and calculi in, 495 

operation on, 491 

prolapse of, wall of, 497 

BUrgery of, 461 

treatment of, diseases of, 495 
Bouilly's operation, 192 
Botemann's catheter, 38 
Broad tigamenta, Lgature of, 260 
Brusque dilatation under anesthesia, 116 
Budin's catheter, 38 
Bulb of vulva, 99 

Calcium carbure in cases of inoperable 

cancer in, 2S 
Canal of Nuck, 100 

of the urethra, examination of, 473 
Cancer of the uterus, abdominal hysterec- 
tomy for, 357 
indication for abdominal hysterec- 
tomy in, 360 
involvement of glands in, 358, 
modiRcation of the operation of ab- 
dominal hysterectomy for, 371 
modification of the operation of hys- 
terectomy for, 369 
vaginal hysterectomy in, 261 
operation of hysterectomy for, 361 
Cancers of the urethra, 490 
Cannulas, 24 
Canquoin'fi paste, 45 
Carbon electrode, 75 
Cataphoresis, 78 
Catarriial metritis, use of mineral water in 

the treatment of, 96 
CathcteriEation of the ureters, 479 
of the urethra, 481 
of the uterus, 29 

contraindication to, 30 
indicatioii for, 30 
Caustic pencils, 45 

Caustics, application of to uterine cavity, 45 
method uf application to interior of 
uterus, 46 
Celiotomy, abdominal. 293 
complication of, 323 

al'sccss of the wall following, 326 
acute dilatation of the stomach fol- 
lowing. 325 
eventration following, 328 
intestinal occlusion following, 325 
internal hemorrhage following, 323 
late intoxication by anesthesia fol- 
lowing. 32)) 
M'ptic peritonitis following, .324 
parotitis following, 32-^ 
phlebitis following, 327 



Celiotomy, pulmonary complications of, 
326 

pyo-stercaral fistulas after, 327 
retention of urine after, 32S 
shock following, 323 
slight peritonitis following, 324 
unnary fistulas following, 327 
median and transverse, after-treat- 
ment of, 321 
transverse, 320 
Cervical fibromata, removal of, 203 
Cervix, amputation of, 1S4 
with the knife, 190 
with the galvanocautory of, 190 
Bouilly's operation on, 192 
indication lor amputation of, 189 
for definite occlusion of, 177 
for temporary occlusion of, 177 
infravaginat amputation of, 184 
occlusion of, 177 
one flap amputation of, 186 
Powey s operation on, 192 
position of as found in vaginal exami- 
nation, 10 
scarification of, 192 
supravaginal amputation of, 189 
the two Itap amputation of, 185 
various operations on, 192 
Ccstokausis, 52 
Chancre of the vulva. 111 
Choice of operation in pregnancy, compli- 
cated by uterine fibroids, 435, 436 
Chronic adnexitis, 423 

conservative treatment of, 424 
surgical treatment of, 427 
metritis, treatment of, 418 

Enera), 420 
:al. 417 
cauterization in, 418 
curettage in, 419 
vaginal dressings in, 418 
Cicatricial constriction, treatment of, 108 
Cicatricial constriction, treatment of, 108 
Circular friction, 89 
Clitoris, removal of, 110 
Colpectomy, 169 
Colpoclesis, 514 
Colpocystestomy, 493 
Col po perineoplasty, Doleris', 161 
Colpoperineorrhaphy, 142 

by division ana splitting, 151 
by resection, 142 
Colporrhaphy, anterior perineal, 167 
Colpotomies, 213 
Colpotflmy. anterior, 219 

indication for, anterior, 233 
posterior, 213 
result of, 230 
Combination of anterior colporrhaphy, 
with amputation of the cervix, 
167 
Complete central rupture of the perineum, 

Ml 
Complete riipturt' of, 156 

tear of the perineum, 156 
Comphciitions in thi! use of pessaries, 58 
ot celiotomy, 323 
to uterine curettage, G5 



INDEX 



527 



Congestive metrorrhagia of puberty, uw of 
mineral water in the treatment 
of, 96 
Conservative operation, 353 

on the ovary, 389 
Constriction of the vagina by metallic 
sutures, 168 
Freund'a method of, 168 
Continuous irrigation, 40 

of the uterus, complicationB arising 
during, 42 
Contusions of the vulva, treatment of, 101 
Courty's operation, 179 
"Cri uterine," 63 
Crucial incision of the cervix, Fritsch'a 

incision, 178 
Cuneohysterectomy, 404 
Curative treatment of fistulas of the ureter, 
S19 
of metritis, 415 
Curettage of the bladder, 494 

of the uterus apart from the puerperal 
state, 70 
indication for, 68 

in the puerperal state, 08 
Curettine of the uterus, 60 

of the uterus aa a curative agent, 71 
exploratory, 70 
for puerperal metritis, 416 
in cancer, 71, 72 
hemorrhage following, 66 
Cuscob' speculum, 16 
Cutaneous tumors of the vulva, 112 
Cystoscopy, 476 
Cystitis, 496 
C^sts of Bartholin's glands, 113 

of the vagina, treatment of, 123 



David's hysteroscope, 21 

Deep inflammatory lesion, treatment of, 

104 
Definite occlusioo of the cervix, indication 

for, 177 
Denudation by splitting outward from the 

fistula, 506 
De Pezzer's catheter, SOS 
Dilatation of the urethra, 481 

of the uterus, 31 
Dilator with three blades, 32 
with transverse groove, 32 
with two blades, 32 
Direct obliteration of vesico-uterine fistu- 
las, 514 
Diseases of the bladder, treatment of, 495 

of the urethra, treatment of, 489 
Displacements and deviation of the uterus, 
abdominal operation for, 393 
of the uterus oa diagnosticated by 
bimanual examination, 11 
Division of the vulvo-vaginal tissues, 108 
Dobourg's, procedure of, 169 
Doleris' brush, Rh 
catheter, 38 
colpoperi neoplasty. 151 
Doyen's anterocolpoceliotomy, 229 

hemisection of the uterus in vaginal 
hysterectomy, 243 



Doyen's operation for vaginal hysterec- 
tomy tor prolapse, 269 

for recto-vaginal fistula, 172 
vaginal hysterectomy, 256 
Drainage of uterus, 47 
Dudley s operation, 402 
Duhrssen's method of fixation of the 

uterus, 224 
Dumontpallier's pessary, 55 

Eciema of vulva, treatment of, 103 
Electrode, active, 75 

carbon, 75 
Electrodes, 74 
Electrolytic introduction of metallic ions, 

78 
Electrotherapeutics as a means of treating 
metritis, 84 
motor action, 79 
indications for, SI 
X-rays in, 80 
Electrotherapy, 73 

chemical action in, 76 
instruments for, 73 
Elevation. 89 

EIcphantiaHis of the vulva, 112 
Episiorrhaphy, 107 
Epithelioma of uterus, treatment of, 438 

of the vulva, 114 
Erythraama of vulva, treatment of, 103 
Eversmann's cupping apparatua, 53 
Exaggerated moliility of the uterua, 452 
Examination of the bladder, 475 
of the. kidneys, 479 
of patient suffering from steribty, 469 
of the ureters, 478 
of the urine, 472 
with the speculum, 15 
Excision of the hymen and of the vaginal 
entrance, IIB 
of inflammatory lesions of the vulva, 

111 
of labia minora, IfKl 
Excrescences of the urethra, 489 
Exploratory curettage of the uterua, 70 
Extenaive anterior oolporrhaphy for colpo- 

cystocele, 103 
External jienitalia, inspection of, 9 
Extrauterine pregnancy, 460 

after fifth month, management of, 
when fctua is hving or viable, 462, 
403 
after five months' management of, in 
cosCK when the fetus is dead, 463 
complication in the evolution of, 460 
expectant treatment in, 401 ■ 

neresNity of operating on, 461 •*" 
observed in the coursti o( the first 
five months, 461 t^l 

removal of gravid tube in, 461 
treatment of after five months, 462 
Extrauterine symptoms in gynecological 
conditions, & 

Failures in curettage of the uterus, 67 
Faure's, J. L., procedure in vaginal hya- 

terectomy, 259 
F'edorow's operation on the Vtigfjat, lU 



528 



INDEX 



Ferguason'fl cylindric&l apeculum, 16 
Fibromyoma of the vagina, treatment of, 

123 
FibromBta and myomata of the urethra, 
480 
hvaterectomy for gsnereDouB, 353 
ol the uteniH. removal by the vaginal 

route, 202 
vapnal hysterectomy in, 263 
Filho'a nougies. 46 

polypus, removal ot, 202 
Finger, uiie of as an aid in curettage of the 

uterus, 68 
Fiatula, operative treatment for vesico- 
vaginal, 501 
Fistulas, preoperative treatment of vesico- 
vaginal, 500 
treatment of urinary, 498 
vesico-utenDe, 514 

direct obliteration of, 514 
indirect obliteration of, 515 
of the ureter, 518 

uretero- vaginal with destruction of 
the urethra, 515 
Flap-Hplitting operation in vcaico-vaginal 

fistula, 506 
Folding up and fixation of the tubes to the 
anterior wall of the utcrua, 402 
of the round ligament and fixation of 
the fold to the posterior surface 
of the uterus, 403 
Foreign bodies in the vagina, treatment 
of, 120 
and calculi in bladder, 495 
and calculi in the urethra, 487 
Formation of a neo-vagina, 129 
Fortach's operation, 226 
Fourchette, 98 
Freund's method of const nction of the 

vagina, etc., 168 
Fritach and LoDentu's operation for recto- 
vaginal fistula, 174 
Fritsch'a operation forcrucial incision of the 
cervix, 17S 
procedure for vaginal prolapse, 267 

(lalvanocauterj-, 260 

(iangrcnoB fibromata, hvaterectoray for, 

353 
(iuull's air pessary, 54 

(ieneral anatomy of the uterine arterv, 
198 
conside ratio na in gynecological diug- 

nosis, 1 
indicaliona tor treatment in uterine 

prolapxe, 430 
technic ot abdominal ccliotnmy, L'03 
plastic operation on the perineum juid 
va^Liiu, I3fl 
lit'tiital examinution. t) 
prolapse, 444 

opiTative trcatniiint <if, 410 
OranI Murchaml's (ipcnitirm fur rcrlo- 

vuginiil fistiilus, 174 
(Jrrsurrv's npi-rulion on Vii(;i"ii. l''"> 
Clauds of Bart!ii>litL. <.)l) 

treutiiii'iil (if iiifluinnialiiiti of. 1(14 
vulvDvaginiil. IW 



Gonorrheal metritis, 416 

vaginitis, treatment of, 121 
Gradual dilatation of the uterus, ioriii' 

ments required in, 34 
Gynecological dia^ods, examinaliai 4 
abdomen m, 7 
interrogation in, 7 
physical examination iti, 6 
significance of, absence or vuiiliDt 
in menstruation, 2 
pain in, 4 
awellinea in, 4 
vaginal discharges in, 3 
value of symptoms in, 5 

Hegar's bougie, 32 

procedure for laceration of the peri- 
neum, 150 
urethral bougies, 482 
Hematoma of the vagina, treatment of, 

120 

Hemorrhage, significance of as a symptom, 
3 

following curettage of the uterus, 66 
Hemorrhagic metritis, 420 
Hepncr's operation, 131 
Hodge's pesHary, 55 
Hydromineral treatment, 94 
Hy<lronepliro8iB as diagnosticated by bi- 
manual examination, 15 
Hydrotherapy, 93 
Hvmen ancT vaginal entrance, excision of, 

116 
Hysterectomy, abdominal, 329 

indication for, and modification of 
technic according to the nature of 
the lesion. 347 
for inflammatory diseases of adneu, 
347 
by continuous tranaverse section, 341 
for gangrenous fibromata, 353 
for included fibroids, 352 
by the paravaginal route, 273 

circular separation and closing the 

vagina. 275 
closing of Ihe peritoneum, etc., 280 
disM'ctJou of the bladder and ui«ter, 

277 
freeing the lateral borders of the 
vagina and dissection of base of 
puramclrium in, 278 
history ot. 273 
opi'uiug iif the iH-ritoneum, removal 

iif uterus and vagina in, 279 
11)11' nit ion, 274 
pjiraviiginiil excision, 27(i 
results iind indications in, 281 
by jirimiiry exeision of the uterus. 341 
fnr prc)l;ipse. ;i75 
i[i ]iuerpcnil iiifectiiin. 2fi(i 
fur pueri>er;il sepfie infection. 417 
liv se[i;ir;itirlli. 33S 
:iiiht.itiil, 3:« 
total. :VM\ 

by uterine hemiscetion, '■i\'■^ 
fur uterine rilptun'. :i7ti 

viiginal, 2:i.i. 43:i 

fur eancer iif Uie uterus. 2111 



INDEX 



.»» 



IByBteropexy, aaterior Bbdominal. 393 
ilyBt«ropbores. 54 
HyateroKcope. 21 
Hysteroscopy. 20 
Hysterotomy. 29 

Immediate perineorrhaphy. 139 
Imperforate hymen, operation for. 17 
Imperfomtion of the vagina, oprration for. 

133 
'ncomplete rupture of the perineum. 140 
.^acomplele perineal tears, 151 
. ncontinence of urine, anterior colpor- 
rhaphy an a cure for. 485 
Duret's opprstioD tor, 485 
Fritsch's operation for, 485 
Gersunv's operation for, 485 
Hofmeier'a operation for, 486 
operation for, 484 
Pawhin's, operation for, 485 
Pousson's operation for, 485 
ladicationa for abdominal hysterectomy in 
cancer of the uterus, 360 
and modification of technie ac- 
cording to the nature of the 
lesions. 347 
for amputation of the cervix. 189 
for anterior colpotomy, 2-^3 
and contraindication lo inlra-uterine 
douching, 4.1 
to maiwase, 92 
to vaginal douches, 26 
'or eurrettage of the ulcrus, 68 

in the puerperal state. f>8 
iir lieaturc of the uterine arteries hy 

the vaginal route. 2(H 
for operations for reeto-vni'ina! fistula. 

176 
f ( r supravaginal ampiitution of the 

cervix, 131 
to- tamponing the vaginn. 28 
to.- temporarv occlusion of the cervix. 

177 ■ 
tor use of elcetro therapeutics. 81 
to the use of pesj^arics. 551 
Indirect hysteropexy. 398 
operation, 400 
indications and results. 4(i(l 
obliteration of vesico-utcrini- li-tuhi, 
515 
Infection following rurn>n:i);(' <'f iW 

uterus. 66 
InfibuUtion. 107 
Inflammation of the uc)nr'\:i, :<sl 
indicution.s, 381 
operation. 3S1 
Inflammatiiry lr-sioti>;, i-M'isiiin nf. 111 
of the vagiiiii. trcalmi'nl of, 121 
of the vulva, trt'nlnnTil of, 1112 
Infravaginiil ani[>u(:itiiiii i>r the i-iTvix, IS) 
Injections, LiilrauliTini', II 
Inoperable imucit of llii' |.r<'i;n:iiit ulcrii-, 

treutnictit nf, 4 11 
Inspection, 7. !> 
Instrumi'iits fur i'li'i'lriillicTa|i\ . 7.! 

ri'i(iliri'i| ill niphl ilii^ilatiim cif ihr 

UllTII«. HI 

Insutnatiii^ \r.iil. ■'> I 
at 



latemal pudic nerve, resection of. 117 
urethrotomy, indications for. 4^ 
Interrogation. I. 2 

of patient suffering from Uisea.-v i<X the 
genito-urinary system. 471 
Interstitial myomata, con^servativv opera- 
tion tor. 354 
Intestinal hemorrhage following c^liotomv. 

323 
Intestine, transnlantation of. IM 
intra-abdominal shortening of thr tvunU 
ligaments. 4 IX) 
of the utero-sacral liganieDt», 4t>6 
Intra-uterine application of ek-elricity. 77 
douche. 40 
douching, indications anil ointnt- 

indication. 43 
injections. 44 

accidents arising fnini. 45 
irrigation. 416 
lavage, 37 

in the non-puerperal state. 43 
in the piieri»eral state. 37 
in the puerperal state, instru- 
ments rei)uireil, 37 
in the puer]H'ral state, teelinic I'f. S9 
medication. 37 
Introfluctii'ii of Huid or air into the vein* 

<luring intni-ulerine douche. 42 
Irrigating curetti'. 64 
Irrigation, rontinuous. 40 
Instruments for vaginal injection. 22 
Inversion of the [nierperal uterus. 457 

of the uterus, 45i 
Isaac's operation, 132 

Jacobs" ligmnentary tmclieloji'vy. 45(1 
Jaylr's liiviilve .-ipt'cllluni. 16 
Juxla-uterine tumors, vaginal hysterec- 
tomy for, 271 

Kelly's conical dilator, 47S, 4S2 

operation fi)r colpocysti)tomy. 193 
Kidneys, examination of. 479 
KiTietotherapy. SS 
KiiPt'-eli'ow |iositUin, 20 
Kra.-iki's o)>er»lion fur perineot<imy. 284 
Kriiurosis, Ireiittni'nl of. M'.'i 

i,alii!i iiiajora, blood sujiplv of, IIHI 
lyniphalirs of. 101 
minora, excision of. 1(16 
tri'iilnicnt of adhesion of the, 107 
Ijlivralioii of iiiTiiicnni. Ireatnient of, 138 
jjile periiieiirrhiipliy. III 
Ij'fouf's 1 iilie, IS 
I.efl hilenil position. 19 
l,i'ueopla-.La. Ireiituieul of. lO.'i 
I.eiicorrlieal form of metritis, 42tl 
l.i^aturi' of the liroH^l ligaments. 260 
of (lie liypocaslrie veins, 411 
e\lrii|>iriloiie:il route, 411 
(raii'periloneiil route, 411 
of (he uterine iirteries by the vaginal 
roii(e, 19K 
bv (lie vaginal route, indications 

"for, 2(11 
by the vaginal route, oprmtivfl 
' li'i'linie <il, 2\*i 



530 



INDEX 



ligature of the uterine artery by the ab- 
do initial route, 409 

across the broad ligaments, 410 
at the level of the ovarian fossa, 409 
Leguen's operation for recto- vaginal 

fistula, 176 
Lithotrity, 494 
Local hyperenuB, apparatus for producing, 

52 
Lupus of the vulva, 111 
Lymphangitic abscess, treatment of, 1D4 

Mackcnrudt's operation for literal fistula, 

520 
Malaxation or kneading, 90 

of the vulva, 114 
Malignant tumors of the vagina, 124 

of the uterus, 436 

chemical caustics, 438 
epithelioma, 438 
removal of uterus for, 437 
treatment of sarcoma of, 437 
UHL' of X-ray in, 438 
Massage, 89 

indications and contraindications, 93 
Median celiotomy, 299 

abdominal iiiciuion in, 301 

closing the abdominal wall in, 308 

ilifFerent methods of suture, 312 

drainage in, 315 

dressing of, 318 

examination of the appendix in, 308 

hcmostoHis, 307 

lavage of the peritoneum in, 318 

limitation of the operative tield in, 303 

preliminaries of the operation, 299 

treatment of adhcHions in, 305 
Menopause, troubles of, 468 
Menorrhagia and metrorrhagia, 466 

definition of, 3 

significance of as a symptom, 3 
Menslrual troubles and sterility, 465 
Menstruation changes in as a symptom of 
iliMease, 2 

supplementary, 466 

trr)ubleB of. 465 
Method of genital examination, 9 
Metritis, acute, treatment of, 416 

causes of, 414 

hemorrhaeic, 420 

!;onorrheal, 4)6 
cueorrheal of, 420 
septic, 416 
treatment of, 413 
curative, 415 
pniphylactie, 415 
uBcof electricity in the treatment of, 81 
Mctrorrbagia, definition of, 3 

occurring at menopause, use of min- 
eral water in the treatmcnl of, 06 
siKnilicRnce of, 3 
Mirliaux. procedure, 109 
Minor cyni-cologv, 22 
Miihili'. retrodeviation of, 454 
Miiliirit'u witliout nieiistriial rclctilioii, I2<) 
Mnrcc'lk'nirnt, 210 
Muvi'iNrnts, HO 

incTi'iisiiig cimgi'slion. 01 



Movements, lessening congestion, 90 
Mucous vulvitis, treatment of, 103 
Mud baths, 95 
MuUer'a method for total removal of 

vagina, 171 
Myomata coDservative operation for re- 
moval of interstitial variety, 354 
pediculated, conservative operation 
for, 354 
Myomectomv, abdominal, for uterine fib- 
roid, 432 
morcellement for, 210 
transvaginal, 202 
trans vagi no-uterine, 204 

Neoplasms of Iheadnexa, treatment of, 31^2 

adhesions, 385 

included cy^ts, 385 

extirpation of small growths, 382 

operation, 382 

operative complications, 385 

removal of large cystic tumors, 382 
use of electrotherapeutics in, 88 
Neova^na formation of, 129 
Nephrectomy, 523 

Nervous dysmenorrhea, use of static elec- 
tricity in, 81 
Xourse's operation for anteflexion of the 

uterus, 195 
Nymphorrhaphy, 107 

Obliteration of the pouch of Dougl&s, 407 
of the uterine cavity following curet- 
tage of the uterus, 67 
Occlusion 01 the cer\ix, 177 
Old complete perineal tears, 142 

and complete tears of the perineum, 

148 
tears of perineum complicated by 
prolapse, 149, 158 
One-flap amputation of the cervix, 186 
Oophorectomy, 380 

Operation for enlarging the vulvar orifice, 
107 
on the bladder, 491 
on tbc cervix and pregnancy, 195 
constricting or closing the vulva, 107 
from incontinence of urine, 484 
for rectovaginol fistula by the perineal 

rout, 174 
for rectovaginal fistula by the vagi- 
na) route, 171 
for n'ctovaginal fiKtula by the vagino- 
perineal route, 176 
on the tulies and ovaries, 378 
111! till! un'thra, 481 
•111 ibe urinary apparatus, 471 
fur uterine tli>\ions, 103 
fur vi'siriiviiglnal fistula, 501 
on the vulva, 106 
Opcralive Mii>ililir':ition according to the 
iiiitiiri' iif till) lesion, 261 
Ici'linie <if lijiiiturf of the Uterine 
(irli'rie-; by the vafiiniil route, 200 
treat iiir'iit iif PiineiT of I lie Uterus, 361 
Ireiiliut'iit III' pniliipnccif the uterus, 440 
( lr);ani(' leniiiiis, ii-e nf electrotherapeutics 
in. M 



INDEX 



531 



Ovariopexy, 390 

Ovariiiii cysts, removal of layer, 382 

grafts, 391 
Ovary, conservative operation on, 389 

tumors of, 442 

io pregnaut women, 443 

Pain as a general symptom in gynecologi- 
cal conditions, 4 
Palliative treatment of inoperable cancer 
of the vagina, 125 
of uterine tibromata, 430, 431 
electricity in the, 431 
use of X-ray in, 431 
j)alliative medical treatment, 430 
Palpation, 7 

Papillary cysts, removal of, 442 
Paravaginal route, hysterectomy by the, 

273 
Pasteau's straight urethrotome, 4S2 
Patient in position tor curretting of the 

uterus, 62 
Payne's operation tor ureteral fistula, 522 
Pcan and Segoud's hysterectomy, 205 
Pean's hysterectomy, 2,'>8 
Pediculatcd mvomata, conservative opera- 
tion for, 354 
Pelvis, vertical and transverse section of, 

100 
Penetration of fluid into the peritoneum, 

42 
Percussion, 7 

Perforation of the uterus during curettage, 
66 
of the uterus from introduction of 
catheter, 42 
Perineal lacerations, prevention of, 138 

treatment of, 138 
Perineal and sacral routes, perineotomy 
by the, 282 
section, 491 
_ tears (old), 142 
Perineorrhaphy, colpo-, 142 
immediate, 139 
late, 111 
secondary. 141 
Perineotomy, 282 

operation of Hochenegg, 284 
iiperation of Roux, 284 
hy parasacral route, 283 
bv sacral roul«, 283, 284 
sagittal, 283 
transverse, 282 
Perineum, complete tears of. 156 
incomplete tears of, 151 

rupture, 140, 141 
Ilcgar's procedure tor laceration of, 

150 
ol<l and complete tears of, 148 

tcirs of, complicated by prolapse, 
118, l.W 
Talc's procpdiire for laceration of, 151 
anil vucina, 136 

Veit's procedure for repair of lacera- 
tion of, 148 
Peritoneum, penetration of fluid into, 42 
Periurethral malignant tumors, 490 
Pessaries, 53 



Pessaries, complication in the use of, 58 
indication to the use of, 59 
mode of introduction and details to 

observe. 56 
use of in retrodeviation of the uterua, 

455 
vaginal, 54 
vagi no-abdominal, 54 
various types, 53 
Pessary, Dumontpallier's, 55 
GauU's air, 54 
Hodge's 55 

Schultie, fiBure-of-S, 55 
Schultie's sledge-formed, 56 
PestaloKza's operation, 405 
Petit's drain, 48 

Phlebitis following celiotomy, 327 
Physical cxamiriation, 6 
Physiological bases, 73 
Pinard's catheter, 37 
Pincus apparatus, 49 
Plastic occlusion of the ureter, 519 

operation on the hymen and vaginal 
entrance, 116 
on the perineum and vagina, 136 
^'neral technic of, 136 
Polypoid inversion, 458 
Positionsof patient takinga vaginal douche, 

24 
Posterior colpotomy, 213 
indications for, 216 
operation. 213 
results of, 216 
Postoperative details of vaginal hysterec- 
tomy, 250 
Pouch of Douglas, obliteration of the, 407 
Pouey's operation, 192 
Pom's operation, 181 

for ureteral fistulas, 520 
sound, 137 
Pregnancy complicated by uterine cancer, 
440 
extrauterine, 460 
Preliminarv creation of means of access, 

2(W 
Preoperative treatment of urinary fistulas, 
500 
of vesico-vagina! fistulas, 500 
Prepuce of clitoris, operation on, 106 
I'ressure, 89 

Primitive amenorrhea, 465 
Principal mineral waters used in gyne- 
cology, 94 
Prismatic cystoscope, 476 
Probes for uppl>ing caustics, 47 
Procedure of Dubourg, 169 
Procedures of Quenu and MuUcr, 258 
Prolapse of the uterus, 444 

hvatercctomy for, 375 
Marion's operation of obliteration 
of the pouch of Douglas for the 
cure of , 407 
operative treatment of, 449 
of the urethral mucous membrane, 48B 
of vesical mucous membrane, 497 
l'r<)t if prating urethritis, 488 
Prophylactic medical treatmeot of pn^ 
' lapiM.', 448 



532 



INDEX 



Prophylactic medical treatment of fistijlM 
of the urct«r, 519 
of metritis, 413 
of vesico- vaginal liHtulas, 400 
Pruritis vulva;, treatment of, 105 
Puerperal infection, hysterectomy in, 266 
inversion, 457 

septic infection, hysterectomy for, 417 
state, intrauterine lavaee in, 37 
Pulmonary complications following cehot- 

omy, 326 
Pyostercoral fistulas following celiotomv, 
327 

Radical treatment of uterine fibroids, 432 
Itupid dilatation of the uterus. 31 

inHlrumcntx required in, 31 
Rectal examination, 15 
Itectovaginul fistula, indication for opera- 
tion for, 176 

operations by the vaginal route, 171 

liy |>erineal route, 174 

l>y the vaginoperineal route, 176 

Sanger's operation for, 172 

Doyen's operation for, 172 

Fritsch and 1^ Dentu's operation for, 

Schauta's method for, 171 
treatment of, 171 
Reduction of uterine invention by the 

ul)dominul route, 412 
KcccI'm operation tor anteflexion of the 

uterus, 194 
Removal of the adnexa, 378 
of clitoris, 110 
of cervical fibromata, 203 
of fibrous polyps, 202 
of fibromata by the vaginal route, 202 
lit hcaltliv adnexa, 378 
operation, 378 
indication for, 379 
of heultliy ovarv in cases of ovarian 
cyst. 443 
Resection of the internal pudic nerve. 117 
Itetrodevifttions of the uterus, 453 

use of pc-ssurieii in, 435 
llcl roHcxion of tiic Rravid uterus, 456 
Rieard's (i[>eralion for uretlirul grafting, 

521 
Ring curcKi'. 6.3 
Roehert's iiiiHlifienlion of eolpocvHtotomy. 

403 
Rosiier's operation, ISO 
R<innil ligiiiiienls. fiiliiing up for the fixation 
of the fold to the posterior surface 
of the uterus, 403 
of the uterus, 403 
fohiing up and fiviilion to the anterior 

.surfnei' of the uliTUS. W2 
intrauhdiiniiiuil shortening of, 4IHI 
.~hiirt<'niiiKr)f, LI) till' inguinal canul, 2H6 
simple frilling of, 401 
lludolph, ■!.. iippuralus for jiroduciiig iher- 
niii" iirdon in liical liypiTrmia, ii'l 
Ru1l> fur intrnduition of catheter inl<i llie 

UllTllS. 10 

Rupliir<' of the ii1iTu>, livsieri'i-dimv for. 
37li 



Sanger's operation for recto- vaginal fistul & 

172 

sagittal perineotomy, 2S3 
Sarcoma of uterus, treatment of, 437 
Scarification of the cervix, 192 
Schauta's nnethod of operation for recto- 
vaginal fistula, 171 
Schroder's one-flap amputation of the 

cervix, 186 
Schultae's figure-of-8 pessary, 55 

sledge-formed pessary, 56 
Schwartz operation, 134 
Sclerous urethritis, 489 
Sebaceous vulvitis, treatment of, 103 
Secondary amenorrhea, 466 

perineorrhaphy, 141 
Segond'a operation, 257 

resection for recto- vaginal fistulas, 174 
Sellheim's operation for ureteral fiatulaa, 

520 
Septic metritis, 416 

SeritonitJs following celiotomy, 324 
following celiotomy, 323 
Shortening of the round ligaraents in the 
inguinal canal, anatomical recap- 
itulation, 286 
operative l«ehnic, 287 
various modifications of operation 

for, 290 
resnits and indications, 291 
region, 286 
of the utenisacral ligament, 218 
Simon-Marckwald's two-flap amputation 

of the cervix, 185 
Simple denudation operation for vesico- 
vaginal flstulas, aOZ 
folding of the round ligaments, 401 
inspection of the urethra, 473 
Sim's duckbill speculum. 16 

im'thoil of introducing, 19 
position. 19 
Sis mo therapy, 93 

Slow dilatation of the uterus, indications 
for, 36 
or gradual dilatation of the utcruB, 34 
Some rare abdominal operations, 4U7 
Special procpiiures in operation for vesico- 
vaginal HstulnB, applicttl)le to 
large lo.sses of substance, 511 
flaps, 511 

Pntsch operation, 511 
Trendelen berg's suture. 511 
Odeiitbul's modification, oil 
operation in stages, 512-513 
S]iecmuin. Cusni's, 16 

examination with, 15 
Fergiisson cylindrical, 16 
nii'tlirid (jf in(n"lucing, 16, 27 
manner of n'movitig. 17, 18 
Jjivle's hivalve, 16 
.Sim's iluokbill, Iti 
Speculums, varieties of ilicusped. 15. 16. 
Spiiielli's iij>criiiiiin. 220 
Split I lug of tb<- aiiteriiir wall of tlu' vagina 
iuid sulim'sof the le vat ores ani 
niiisrles. liW 
outward from an incision at a distance 
frmii I be fistula, 307 



INDEX 



533 



Standing position, 19 
Stenosis of the vagina, 126 
SteriUty, 469 

treatment ot, 470 
Stricture and obliteratioD of the uterine 

cavity following curettage of the 

uterus, 67 
Stomatoplasty, Pozii'a, 181 
Stroking, 90 

Stricture and atresia of the vagina, 123 
Subcutaneous tumors of the vulva, 113 
ijubtotal hysterectomy, 334 
Suburethral abscess, 489 
Supplementary menstruation, 460 
Supravaginal amputation of the cervix, 189 

indication for, 161 
Surgery of the Bladder, 4S1 

of the urethra. 481 

of the vagina, 119 

of vulva, 98 
Swellings, 4 

causes of, 4 

Tait's procedure for reyiair of laceration of 

perineum, 151 
Tamponing of tlie vagina, 28 
Tampons, 7 

Technic of intrauterine lavage in the puer- 
peral state, 39 
of instrumental dilatation of the 

uterus, 31 
of vagina! irrigation. 24 
Tenaculum forceps, 62 
Tentu, technic of, introducing, 35 

technic of removal of, 36 
Therapeutic indications in disease of the 
genital system of woman, 413 
for mineral waters, 96 
Thiersch's grafts, 132 
Thiriar and Jonneaco's anterior cuneo- 

hysterectomy, 404 
Total hysterectomy, 336 

by subperitoneal dicorti cation with 
primary opening of the posterior 
tornixand with preliminary hemo- 
stasis, 345 
Trachelorrhaphy, 182 
with flaps, 184 
with surface denudation, 183 
Trachelotomy, 178 

Courty',s operation for, 179 
Poiii's, 181 
Uossner's, 180 
Transplantation of the intestine, 134 
Trunsvagiuul myomectomy. 212 
Trans vagino-ulerine myomectomy, 204 
after-treatment of, 212 
indications for, 212 
sulur<' of the cervix after, 211 
treatment of situs occupied by the 
tumors an<l of the uterine cavity 
after. 211 
Transverse celiotomy, 320 

perineotomy, 2X2 
Treatment of benign tumors of the vulva, 
112 
of chronic metritis, 418 
of cystitis. 496 



Treatment of cvsts of the vagina, 123 
of deep innammatory lesions, 104 
of diseases of the bladder, 495 

of the urethra, 487 
of dysmenorrhea, 467, 468 
of early extrauterine pregnancy, 416 
of extrauterine pregnancy after the 

fifth month, 462 
of fibromyoma of the vagina, 123 
foreign bodies in the vagina, 120 
of fistulas of the ureter, 518 
situated in the neighborhood ot the 
cervix uteri, 509 
operation of the above in several 
stages, 509 
of gonorrhea! vaginitis, 121 
of inflammation of the adnexa, 422 
of malignant tumors ot the vagina, 124 
of hematomas of the vagina, 120 
of inflammatory lesions of the uterus 
and adnexa, 413 
of the vagina, 121 
of inversion of the puerperal uterus, 

457 
of menorrhagia and metrorrhagia, 448, 

467 
of metritis, 413 
of acute, 415 
of gonorrheal 416 
of septic, 416 
of neoplasms of the uterus and 

adnexa, 429 
of operable cancer at time of accouch- 
mont, 441 
in early pregnancy, 440 
of perineal tears, 138 
ot polypoid inversion, 458 
of primary and secondary amenor- 
rhea. 465, 4 G6 
of recto-vaginal fistulas, 171 
of stenosis of the vagina, 126 
of sterility, 470 
of stricture and atresia ot the vagina, 

125 
of traumatic lesiontiof the vagina, 119 
of troubles of the menopause, 468, 469 
of tumors of the vagina, 123 
of urinary fistulas, 498 
of uterine deviations, 451 
fibroid in pregnancy, 434 
cancer in pregnancy, 440 
inversions, 218 
of ut^iTo- vaginal fi.'itulus with destruc- 
tion of the urethra. 513 
of vaginitis, 121 
of vesicovaginal fistula, 5(K) 
of wountle of the vulva. 101 
Tripier's hollow dilator, 482 
Troubles of the menopause, 468 

of menstruation, 465 
Tubes and ovaries, operation on, 378 
Tumors of the ovary, 442 
and pregnancy, 443 
of the urethra, 489 
Two-flap amputation of the cervix, the, 185 

irrcteral grafting, 320 
Ureter, fistulas of, 518 



534 



INDEX 



Ureter, causes of fistulas of, 518 
prophylactic treatment of, 519 
curative treatment of, 519 
plastic occlusion, 519 
ureteral grafting, 520 
Ureters, vaginal examiDation of, 478 

fistulas with destruction of the urethra, 
515 
Ureters, abdominal palpation of, 478 
examination of, 478 
technic of catheterization of, 479 
Urethra, dilatation of the, 481 
elimination of, 472 
exploratory eutheterixation of, 474 
surgery of, 481 
treatment of diseases of, 487 
of suburethral abBcess, 489 
of urethrocele, 489 

prolapse of urethral mucous mem- 
brane, 489 
tumors of, 489 
of wounds of, 487 
of foreign bodies io, 487 
of urethritis, 487 
Urethrectomy, indications for, 483 

technic of, 483 
Urethritis, 489 
Urethrocele, 489 
Urethroscope, 474 
Urethrotomy, indications for internal and 

external, 483 
Urinary apparatus; method of interroga- 
tion of patient suffering from 
diseases of, 471 
operations on, 471 
fistulas, 498 
Urine, examination of, 472 

operation for incontinence of, 484 
Uterine arteries, general anatomy of, 198 
indications for the ligation of by the 

vaginal route, 201 
ligature of, by the vaginal route, 198 

by the abdominal route. 409 
operative technic of ligation of by 
the vaginal route, 2G0 
cancer, abdominal hysterectomy for, 

357 
treatment of at time of accouchmcnt, 
441 
in early prefinaney, 440 
and pregnancy, treatment of. 440 
cathctcriiiution, contraindicatioas to, 
30 
instruments used in. 29 
lisp of suund.^ and bougies in, 29 
ti^chiiic of. !<0 
cavity, application of mi'iiicalcd 
biiugies and caustics to, 4-5 
Iciiftth of, :»( 
cun-ltc', fi3 

i'Uri'tl;iKi', ripcTixlioii for, HI 
p:ilL<'iit in piisilion for, ll'2 
iii\i;itiiiM. tri-iitincnts of, 4.i7 
fihriFiil-i in [in-itniini^v, rlmii'c of opcra- 
liiiii. l:l.), r.ii'i 
r;iiiii:il Iri'alnicnt iif. V.Vl 
prfi;ibiiiii'y. Iri-iitiiii'lit of. llll 
tihri'lliii1a,vii);ln]il liysti'rccliiniyin.^fi:! 



Uterine arteries, treatment of, 423, 430 
surgical, 431 
flexions, operations for, 193 
inversion, 457 
reduction of, by the abdominal 

route, 412 
treatment of, 218 
vaginal hysterectomy for, 270 
prolapse; general indications ia the 
surgical treatment of, 450 
prophylactic and medical treat- 
ment of, 448 
vaginal hysterectomy for, 266 
rupture, hysterectomy for, 376 
subinvolution, use of electricity in the 
treatment of, 87 
Uteroplasty, 228 

Uterosacral ligaments, intraabdominnl 
shortening of the, 406 
shortening of, 218 
Uterus, abdominal operations for dispUcc- 
ments and deviations of. 393 
anatomy of the supports of, 444 
and adnexa, treatment of inflamma- 
tory lesions of, 413 
treatment of neoplasms of tbc, 423 
anteflexion of, congenital and acquired, 

453 
Bascule of, 217 
catheterization of, 29 
complications arising during curret- 

tage of, 65 
curettage of, apart from the puerperal 
state, 70 
in cancer, 71 
curretting of, 60, 61 
OS a curative agent, 71 
for puerperal metritis, 410 
dilatation of, 31 
drainage of, 47 
exaggerated mobility of, 452 
exploratory curettage of, 70 
failure in curetting, 67 
lixulion of, by method of Duhrssen 

224 
folding up and fixation of the tube 

to the anterior wall of the, 402 
hemorrhage following curettage of, 66 
hysterectomy for prolapse of, 375 
imperfect introduction of catheter 

into, 40 
indications for the curettage of, 68 
in the puerjH-ral state, 68 
slow dilatation of. 36 
malignant tumom, 436 
method of applying caustics to, 46 
method of introducing catheter into, 

40 
mobile retrodeviation of, 454 
pcrforulion of, during curettage, 66 
relroiU'viation of, 453 
retr<i1ic\iiin of the gravid, 456 
slow iir jinidual dilatation of, 34 
sterility, stricture and obliteration of 
thV uterine cavity following curet- 
tiige of. Cm 
technic of instrumental dilatation of, 
33 



INDEX 



535 



Uterus, treatment of inoperable cAocers of 
the pregnant, 441 
polypoid inversion of, 458 
prolapse of, 444 

Vagina, absence of, without complicationa, 
]29 
atresia of, 127 
constriction of, by metallic sutures, 

168 
incision of (colpotomy), 213 
indications for tamponing, 28 
malignant tumoro of, 124 
Mullcr's method for the total removal 

of, 171 
operation for imperforation of, 133 
palliative treatment of inoperable 

cancer of, 125 
stenosis of, 12G 
stricture and atresia of, 125 
surgery of, 119 
tamponing of, 28 
treatment of fibromyoma of, 123 

of foreign bodies m, 120 

of hematoma of, 120 

of inflammatory lesion of, 121 

tumors of, 123 
Vaginal application of electrotherapeutics, 
76 
arteries, operative technic of ligature 

of, by the vaginal roul«, 200 
atresia, 127 

nith menstrual retention, 127 
discharge, i 
discharges, causes of, 4 

varieties of, 4 
douches, medicinal agents used in, 26 
enterocele, 451 

treatment of, 451 
examination, 10 
fornices, position of, as found by 

vaginal examinations, 10 
hysterectomy, 235 

hemorrhage following, 252 

lesion of neighboring organs during, 
233 

wound of the ureter d,uring, 253 

wounds of the bladder during, 254 

wounds of the rectum during, 254 

peritonitis following, 255 

intestinal occlusion following, 255 

eschars following, 255 

for cancer, 2fil 

complication of, 252 

Doyen's, 256 

Doven's anterior hemisection in, 
243 

for fibroids of uterus, 433 

for fihromadi, 260 

in inflnmmutiun of the adnexa, 265 

for juxta-utcrine tumors, 271 

postoperative details of, 250 

operative difficulties of. 251 

Segoiid's "piTution, 257 

J. L. Fnure's procedure, 250 

opcr.itivo teehnic of, 236 

IVnn's, 256 

procedure of Qucnu and Mullcr, 258 



Vaginal hysterectomy in prolapse, 266 

for prolapse Fritsch's procedure for, 

267 
tor uterine inversion, 270 
various procedures, 256 
injectionH, 22 

technic of, 24 
medication, 27 
pessaries, 54 
Vaginismus, treatment of, 115 
Vaginitis, treatment of, 121 
Vagino-abdominal pessary, 54 
Varieties of uterine dilators, 32 
Various operations on the cervix, 192 
procedures for anterior colporrhaphy, 
166 
Veit's procedure, 148 
Vertical and transverse sectioD of the 

pelvis, 100 
Vesical mucoua membrane, prolapse of, 

497 
Vesico- vaginal fistulas, 498 
operation for, 501 
general technic of, 511 
special procedures applicable to large 

losses of substance, 511 
flap splitting, 506 

general technic for operation tor, 501 
simple denudation, 503 
treatment of fistulas situated in the 
neighborhood of the cervix uteri, 
509 
operation in several stages, 509 
preoperative treatment of, 500 
prophylactic treatment of, 499 
Vesico-uterine fistulas, 514 
Vestibule. 98 
Vibration, 89 
Vulva, bulb of, 99 
chancre of, 111 
cutaneous tumors of the, 112 
elements of anatomy of, 98 
elephantiasis of, 112 
epithelioma of, 111 
erythema of, treatment of, 102 
examination of, 
hematoma of and treatment, 101 
treatment of herpes of, 102 
inspection of, 
lupus of, 111 
malignant tumors of, 114 
molluscum of. 113 
nerves of, 101 

and lymphatics of, 101 
operations constricting or closing th» 

107 
operations for excision of, 110 
subcutaneous tumors of the, 113 
surgery of, 98 

treatment of contusions of, 101 
erythrasma of, 103 

of inflammatory lesions of, 102 
inflamed . sebasceous 

cysts and furuncle, 102 
intertrigo of, 102 
of traumata, 101 
Vulvar orifice, operation tor enlarging the, 
107 



53G 



INDEX 



Vulvar pruritus, treatment of. 105 
Vulvo-vaicinal gland, inflammatton and 
alihcosH •>!. 104 

treatment of. \(H 
Vulvitis. mucoUN, treatment of. 103 

seliaceouH, trestinent of, 103 
Vulvo-VBKinal f[ lands. 99 

tis3UC«, division of , lOS 
\'ulvo-vaf!pnitis of infancy, treatment of, 
10.') 



Watson's operation for complete rupture 

of the perineum. 156 
Wertheim-Schftulo's operation for anterior 

colpotomy, 227 
W6lfler'3 parasact«l perineotomy, 283 
Wounds of the urethra, 489 
treatment of. 487 

X-ravB in electrotherapeutics, SO 

Zuekerhandl's parasacrsl perineotomy, 283 



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N204 Rartraann, H, 

H53s Gynecological 

1913 operation*. 54438-